Chapter 35 NCLEX Questions
1. 1.ID: 809570597
The nurse is administering a dose of digoxin (Lanoxin) to a patient with heart failure (HF). The nurse would become
concerned with the possibility of digitalis toxicity if the patient reported which symptom(s)?
A.
Muscle aches
B.
Constipation
C.
Pounding headache
D.
Anorexia and nausea Correct
Anorexia, nausea, vomiting, blurred or yellow vision, and cardiac dysrhythmias are all signs of digitalis toxicity. The
nurse would become concerned and notify the health care provider if the patient exhibited any of these symptoms.
Awarded 0.0 points out of 1.0 possible points.
2. 2.ID: 809572421
The nurse is preparing to administer digoxin to a patient with heart failure. In preparation, laboratory results are
reviewed with the following findings: sodium 139 mEq/L, potassium 5.6 mEq/L, chloride 103 mEq/L, and glucose
106 mg/dL. What should the nurse do next?
A.
Withhold the daily dose until the following day.
B.
Withhold the dose and report the potassium level. Correct
C.
Give the digoxin with a salty snack, such as crackers.
D.
Give the digoxin with extra fluids to dilute the sodium level.
The normal potassium level is 3.5 to 5.0 mEq/L. The patient is hyperkalemic, which makes the patient more prone to
digoxin toxicity. For this reason, the nurse should withhold the dose and report the potassium level. The physician
may order the digoxin to be given once the potassium level has been treated and decreases to within normal range.
Awarded 0.0 points out of 1.0 possible points.
3. 3.ID: 809572406
What is the priority assessment by the nurse caring for a patient receiving IV nesiritide (Natrecor) to treat heart
failure?
A.
Urine output
B.
Lung sounds
C.
Blood pressure Correct
D.
Respiratory rate
Although all identified assessments are appropriate for a patient receiving IV nesiritide, the priority assessment
would be monitoring for hypotension, the main adverse effect of nesiritide.
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4. 4.ID: 948112347
A patient admitted with heart failure appears very anxious and complains of shortness of breath. Which nursing
actions would be appropriate to alleviate this patient's anxiety (select all that apply)?
A.
Administer ordered morphine sulfate. Correct
B.
Position patient in a semi-Fowler's position. Correct
C.
Position patient on left side with head of bed flat.
D.
Instruct patient on the use of relaxation techniques. Correct
E.
Use a calm, reassuring approach while talking to patient. Correct
Morphine sulfate reduces anxiety and may assist in reducing dyspnea. The patient should be positioned in semiFowler's position to improve ventilation that will reduce anxiety. Relaxation techniques and a calm reassuring
approach will also serve to reduce anxiety.
Awarded 0.0 points out of 4.0 possible points.
5. 5.ID: 809572417
A male patient with a long-standing history of heart failure has recently qualified for hospice care. What measure
should the nurse now prioritize when providing care for this patient?
A.
Taper the patient off his current medications.
B.
Continue education for the patient and his family.
C.
Pursue experimental therapies or surgical options.
D.
Choose interventions to promote comfort and prevent suffering. Correct
The central focus of hospice care is the promotion of comfort and the prevention of suffering. Patient education
should continue, but providing comfort is paramount. Medications should be continued unless they are not tolerated.
Experimental therapies and surgeries are not commonly used in the care of hospice patients.
Awarded 0.0 points out of 1.0 possible points.
6. 6.ID: 809572425
What should the nurse recognize as an indication for the use of dopamine (Intropin) in the care of a patient with
heart failure?
A.
Acute anxiety
B.
Hypotension and tachycardia Correct
C.
Peripheral edema and weight gain
D.
Paroxysmal nocturnal dyspnea (PND)
Dopamine is a β-adrenergic agonist whose inotropic action is used for treatment of severe heart failure
accompanied by hemodynamic instability. Such a state may be indicated by tachycardia accompanied by
hypotension. PND, anxiety, edema, and weight gain are common signs and symptoms of heart failure, but these do
not necessarily warrant the use of dopamine.
Awarded 0.0 points out of 1.0 possible points.
7. 7.ID: 809572413
A patient with a recent diagnosis of heart failure has been prescribed furosemide (Lasix) in an effort to
physiologically do what for the patient?
A.
Reduce preload. Correct
B.
Decrease afterload.
C.
Increase contractility.
D.
Promote vasodilation.
Diuretics such as furosemide are used in the treatment of HF to mobilize edematous fluid, reduce pulmonary venous
pressure, and reduce preload. They do not directly influence afterload, contractility, or vessel tone.
Awarded 0.0 points out of 1.0 possible points.
8. 8.ID: 809572423
A patient with a diagnosis of heart failure has been started on a nitroglycerin patch by his primary care provider.
What should this patient be taught to avoid?
A.
High-potassium foods
B.
Drugs to treat erectile dysfunction Correct
C.
Nonsteroidal antiinflammatory drugs
D.
Over-the-counter H2-receptor blockers
The use of erectile drugs concurrent with nitrates creates a risk of severe hypotension and possibly death. Highpotassium foods, NSAIDs, and H2-receptor blockers do not pose a risk in combination with nitrates.
Awarded 0.0 points out of 1.0 possible points.
9. 9.ID: 809570595
A stable patient with acute decompensated heart failure (ADHF) suddenly becomes dyspneic. Before positioning the
patient on the bedside, what should the nurse assess first?
A.
Urine output
B.
Heart rhythm
C.
Breath sounds
D.
Blood pressure Correct
The nurse should evaluate the blood pressure before dangling the patient on the bedside because the blood
pressure can decrease as blood pools in the periphery and preload decreases. If the patient's blood pressure is low
or marginal, the nurse should put the patient in the semi-Fowler's position and use other measures to improve gas
exchange.
Awarded 0.0 points out of 1.0 possible points.
10. 10.ID: 948112342
The patient has heart failure (HF) with an ejection fraction of less than 40%. What core measures should the nurse
expect to include in the plan of care for this patient (select all that apply)?
A.
Left ventricular function is documented. Correct
B.
Controlling dysrhythmias will eliminate HF.
C.
Prescription for digoxin (Lanoxin) at discharge
D.
Prescription for angiotensin-converting enzyme (ACE) inhibitor at discharge Correct
E.
Education materials about activity, medications, weight monitoring, and what to do if symptoms
worsen Correct
The Joint Commission has identified these three core measures for heart failure patients. Although controlling
dysrhythmias will improve CO and workload, it will not eliminate HF. Prescribing digoxin for all HF patients is no
longer done because there are newer effective drugs and digoxin toxicity occurs easily related to electrolyte levels
and the therapeutic range must be maintained.
Awarded 0.0 points out of 3.0 possible points.
11. 11.ID: 809570593
After having an MI, the nurse notes the patient has jugular venous distention, gained weight, developed peripheral
edema, and has a heart rate of 108/minute. What should the nurse suspect is happening?
A.
ADHF
B.
Chronic HF
C.
Left-sided HF
D.
Right-sided HF Correct
An MI is a primary cause of heart failure. The jugular venous distention, weight gain, peripheral edema, and
increased heart rate are manifestations of right-sided heart failure.
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12. 12.ID: 809572427
Beyond the first year after a heart transplant, the nurse knows that what is a major cause of death?
A.
Infection
B.
Acute rejection
C.
Immunosuppression
D.
Cardiac vasculopathy Correct
Beyond the first year after a heart transplant, malignancy (especially lymphoma) and cardiac vasculopathy
(accelerated CAD) are the major causes of death. During the first year after transplant, infection and acute rejection
are the major causes of death. Immunosuppressive therapy will be used for posttransplant management to prevent
rejection and increases the patient's risk of an infection.
Awarded 0.0 points out of 1.0 possible points.
13. 13.ID: 809572429
The patient with chronic heart failure is being discharged from the hospital. What information should the nurse
emphasize in the patient's discharge teaching to prevent progression of the disease to ADHF?
A.
Take medications as prescribed. Correct
B.
Use oxygen when feeling short of breath.
C.
Only ask the physician's office questions.
D.
Encourage most activity in the morning when rested.
The goal for the patient with chronic HF is to avoid exacerbations and hospitalization. Taking the medications as
prescribed along with nondrug therapies such as alternating activity with rest will help the patient meet this goal. If
the patient needs to use oxygen at home, it will probably be used all the time or with activity to prevent respiratory
acidosis. Many HF patients are monitored by a care manager or in a transitional program to assess the patient for
medication effectiveness and monitor for patient deterioration and encourage the patient. This nurse manager can
be asked questions or can contact the health care provider if there is evidence of worsening HF.
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