CARDIAC DISORDERS NCLEX EXAM |
QUESTIONS & ANSWERS (VERIFIED) |
LATEST UPDATE | GRADED A+
The nurse is assessing a pt w/ chronic heart failure. Which abnormal chest sound would
the nurse most likely auscultate?
1. expiratory wheezes
PR
2. friction rub
3. harsh vesicular
4. crackles
O
Correct Answer: Answer: 4
FD
Rationale 1, 2, 3: Expiratory wheezes, friction rub, & harsh vesicular sounds are not
associated w/ chronic heart failure.
Rationale 4: Fluid accumulates in the alveolar spaces w/ left-sided heart failure. This
O
fluid causes the sound of crackles at the end of inspiration.
C
When caring for a chronic heart failure pt w/ left-sided failure, the nurse would most
likely note the following statement in the physician's written report following cardiac
catheterization?
1. "Pressures in the left ventricle & atrium are increased."
2. "Pressures in the left ventricle & atrium are decreased."
3. "Pressures in the right ventricle & atrium match the ventricle pressures."
1
,4. "Pressures in the right ventricle reflect functioning of all heart chambers."
Correct Answer: Answer: 1
Rationale 1: As the heart loses its ability to eject blood effectively from the left ventricle
upon contraction, blood is retained in the left ventricle after systole & the chamber
pressure rises due to the added blood volume.
Rationale 2: As the heart loses its ability to eject blood effectively from the left ventricle
upon contraction, blood is retained in the left ventricle after systole & the chamber
pressure rises due to the added blood volume.
PR
Rationale 3: This pt is in left-sided heart failure, so pressure is higher in the left side of
the heart, not the right side.
Rationale 4: This pt is in left-sided heart failure, so pressure is higher in the left side of
O
the heart, not the right side.
FD
A nurse caring for a pt w/ heart failure would expect to find which of the following during
assessment of the pt?
O
1. S1, S2 & flat neck veins
2. S3 & distended neck veins
C
3. S2 is heard the loudest & followed by S1
4. S4 & flat neck veins
Correct Answer: Answer: 2
Rationale 1: S1 & S2 are normal heart sounds; flat neck veins are considered a normal
finding.
2
,Rationale 2: The abnormal S3 sound is reflective of the heart's attempts to fill an already
distended ventricle & the neck veins distend because of the increased venous pressure.
Rationale 3: S1 & S2 sounds may be diminished in the heart failure pt & not vary in
intensity.
Rationale 4: S4 (gallop) may be present but neck veins would be distended.
When obtaining the health history of a pt who is being assessed for possible congestive
heart failure, it is significant when the pt says which of the following?
PR
1. "I break out in a cold sweat when I eat a large meal."
2. "I am sleepy after I eat lunch each day."
3. "I have to prop myself up on three pillows to sleep at night, otherwise I can't breathe."
O
4. "I feel better w/ my legs down when I sit in my favorite chair."
FD
Correct Answer: Answer: 3
Rationale 1: Diaphoresis & sleepiness after meals & comfort when legs are dependent
are all notable findings but not related to a diagnosis of CHF.
O
Rationale 2: Diaphoresis & sleepiness after meals & comfort when legs are dependent
are all notable findings but not related to a diagnosis of CHF.
C
Rationale 3: Needing to prop oneself up w/ pillows at night in order to breathe describes
orthopnea, which is consistent w/ congestive heart failure (CHF). Congestive heart
failure produces a volume excess, congestion in the lungs, & dyspnea when attempting
to lie down.
Rationale 4: Diaphoresis & sleepiness after meals & comfort when legs are dependent
are all notable findings but not related to a diagnosis of CHF.
3
, A pt is admitted w/ acute heart failure. The nurse realizes that acute heart failure is
associated w/ an abrupt onset of which of the following? Select all that apply.
1. cardiomyopathy
2. heart valve disease
3. coronary heart disease (CHD)
4. massive infarction (MI))
5. myocardial injury
PR
Correct Answer: Correct Answer: 4,5
Rationale 1,2,3: Cardiomyopathy, valve disease, & coronary heart disease (CHD) are all
associated w/ chronic heart failure.
O
Rationale 4,5: Pts often present for care w/ signs of acute heart failure when they have
FD
had an abrupt onset of myocardial injury such as a massive myocardial infarction (MI).
Blood tests are ordered for a pt who is diagnosed w/ possible congestive heart failure
O
(CHF). The nurse underst&s which of the following lab tests indicates heart failure? The
most specific test(s) to accurately indicate CHF would be which of the following?
C
1. liver function
2. urinalysis & blood urea nitrogen (BUN)
3. brain natriuretic peptide (BNF).
4. serum electrolytes
Correct Answer: Correct Answer: 3
4
QUESTIONS & ANSWERS (VERIFIED) |
LATEST UPDATE | GRADED A+
The nurse is assessing a pt w/ chronic heart failure. Which abnormal chest sound would
the nurse most likely auscultate?
1. expiratory wheezes
PR
2. friction rub
3. harsh vesicular
4. crackles
O
Correct Answer: Answer: 4
FD
Rationale 1, 2, 3: Expiratory wheezes, friction rub, & harsh vesicular sounds are not
associated w/ chronic heart failure.
Rationale 4: Fluid accumulates in the alveolar spaces w/ left-sided heart failure. This
O
fluid causes the sound of crackles at the end of inspiration.
C
When caring for a chronic heart failure pt w/ left-sided failure, the nurse would most
likely note the following statement in the physician's written report following cardiac
catheterization?
1. "Pressures in the left ventricle & atrium are increased."
2. "Pressures in the left ventricle & atrium are decreased."
3. "Pressures in the right ventricle & atrium match the ventricle pressures."
1
,4. "Pressures in the right ventricle reflect functioning of all heart chambers."
Correct Answer: Answer: 1
Rationale 1: As the heart loses its ability to eject blood effectively from the left ventricle
upon contraction, blood is retained in the left ventricle after systole & the chamber
pressure rises due to the added blood volume.
Rationale 2: As the heart loses its ability to eject blood effectively from the left ventricle
upon contraction, blood is retained in the left ventricle after systole & the chamber
pressure rises due to the added blood volume.
PR
Rationale 3: This pt is in left-sided heart failure, so pressure is higher in the left side of
the heart, not the right side.
Rationale 4: This pt is in left-sided heart failure, so pressure is higher in the left side of
O
the heart, not the right side.
FD
A nurse caring for a pt w/ heart failure would expect to find which of the following during
assessment of the pt?
O
1. S1, S2 & flat neck veins
2. S3 & distended neck veins
C
3. S2 is heard the loudest & followed by S1
4. S4 & flat neck veins
Correct Answer: Answer: 2
Rationale 1: S1 & S2 are normal heart sounds; flat neck veins are considered a normal
finding.
2
,Rationale 2: The abnormal S3 sound is reflective of the heart's attempts to fill an already
distended ventricle & the neck veins distend because of the increased venous pressure.
Rationale 3: S1 & S2 sounds may be diminished in the heart failure pt & not vary in
intensity.
Rationale 4: S4 (gallop) may be present but neck veins would be distended.
When obtaining the health history of a pt who is being assessed for possible congestive
heart failure, it is significant when the pt says which of the following?
PR
1. "I break out in a cold sweat when I eat a large meal."
2. "I am sleepy after I eat lunch each day."
3. "I have to prop myself up on three pillows to sleep at night, otherwise I can't breathe."
O
4. "I feel better w/ my legs down when I sit in my favorite chair."
FD
Correct Answer: Answer: 3
Rationale 1: Diaphoresis & sleepiness after meals & comfort when legs are dependent
are all notable findings but not related to a diagnosis of CHF.
O
Rationale 2: Diaphoresis & sleepiness after meals & comfort when legs are dependent
are all notable findings but not related to a diagnosis of CHF.
C
Rationale 3: Needing to prop oneself up w/ pillows at night in order to breathe describes
orthopnea, which is consistent w/ congestive heart failure (CHF). Congestive heart
failure produces a volume excess, congestion in the lungs, & dyspnea when attempting
to lie down.
Rationale 4: Diaphoresis & sleepiness after meals & comfort when legs are dependent
are all notable findings but not related to a diagnosis of CHF.
3
, A pt is admitted w/ acute heart failure. The nurse realizes that acute heart failure is
associated w/ an abrupt onset of which of the following? Select all that apply.
1. cardiomyopathy
2. heart valve disease
3. coronary heart disease (CHD)
4. massive infarction (MI))
5. myocardial injury
PR
Correct Answer: Correct Answer: 4,5
Rationale 1,2,3: Cardiomyopathy, valve disease, & coronary heart disease (CHD) are all
associated w/ chronic heart failure.
O
Rationale 4,5: Pts often present for care w/ signs of acute heart failure when they have
FD
had an abrupt onset of myocardial injury such as a massive myocardial infarction (MI).
Blood tests are ordered for a pt who is diagnosed w/ possible congestive heart failure
O
(CHF). The nurse underst&s which of the following lab tests indicates heart failure? The
most specific test(s) to accurately indicate CHF would be which of the following?
C
1. liver function
2. urinalysis & blood urea nitrogen (BUN)
3. brain natriuretic peptide (BNF).
4. serum electrolytes
Correct Answer: Correct Answer: 3
4
