NURS 401 EXAM 1 PRACTICE
QUESTIONS WITH CORRECT
ANSWERS
A client is diagnosed with left-sided heart failure. Which assessment findings will the
nurse expect the client to have? Select all that apply.
A. Peripheral edema
B. Crackles in both lungs
C. Breathlessness
D. Ascites
E. Tachypnea - Answer- B. crackles in both lungs, C. breathlessness, E. tachypnea
Rationale: Clients with left-sided heart failure will exhibit symptoms such as fatigue,
dyspnea, or breathlessness, and crackles on auscultation of breath sounds. Peripheral
edema and ascites are associated with right-sided heart failure.
A client has been taking furosemide (Lasix) and valsartan (Diovan) for the past year.
The hospital laboratory notifies the nurse that the client's serum potassium level is 6.2
mEq/L. What is the nurse's best action at this time?
A. Assess the client's oxygen saturation level
B. Ask the laboratory to retest the potassium level
C. Give potassium as an IV insertion
D. Check the client's serum creatinine - Answer- D. Check the client's serum creatinine.
Rationale: Clients who are hyperkalemic may also be in renal failure. The client's serum
creatinine should be reviewed to determine if it is greater than 1.8 mg/dL, at which time
the health care provider should be notified before administering any supplemental
potassium.
An older adult taking digoxin and hydrochlorothiazide (HCTZ) for chronic heart failure is
admitted to the ED with an apical pulse of 48. A family member states that the client has
reported blurred vision and loss of appetite for 2 weeks. What is the nurse's first action?
A. Call the ED physician immediately
B. Draw a serum digoxin level
C. Assess for signs of hypokalemia
D. Establish the client's airway - Answer- B. Draw a serum digoxin level
Rationale: The clinical manifestations of digoxin toxicity are often vague and nonspecific
and include anorexia, fatigue, blurred vision, and changes in mental status, especially in
, older adults. Older adults are more likely than other patients to become toxic because of
decreased renal excretion.
A client who recently had a heart valve replacement is taking warfarin (Coumadin) as
prescribed. What statement by the client indicates that the nurse will need to do
additional health teaching?
A. "I will take my pulse every day, and call my doctor if it is below 60"
B. "I will eat foods that are high in vitamin K, such as kale and spinach"
C. "I will weigh myself every day in the morning using the same scale"
D. "I will take my blood pressure everyday and call if it is too high or low" - Answer- B. "I
will eat foods that are high in vitamin K, such as kale and spinach"
Rationale: pt should be taught to avoid foods that are high in vitamin K, as well as herbs
such as ginger, ginseng, goldenseal, Gingko biloba, and St. John's wort because all of
these may interfere with the drug's action; spinach and kale are high in vitamin K
The nurse is providing education to help reduce cardiovascular risks for a women's
book club. Which statement made by a participant indicates a need for further teaching?
a. "We are more likely to die from cardiovascular disease than men"
b. "We need to walk or do other exercise everyday for 30 minutes"
c. "We need to stay away from people who smoke"
d. "We should take hormones for menopause to decrease the risk for heart attack" -
Answer- d. "We should take hormones for menopause to decrease the risk for heart
attack"
Rationale: meds used in hormone therapy can cause an increased incidence of MI or
stroke in women
A client is admitted to the telemetry unit after a right-sided cardiac catheterization. What
is the nurse's priority when caring for this client?
a. Assess the intensity and quality of the client's pain
b. Position the client in a sitting position to improve breathing
c. Check the client's arterial insertion site
d. Apply oxygen at 2 L/min via nasal cannula - Answer- c. Check the client's arterial
insertion site
Rationale: Pts who have had a cardiac catheterization should be restricted to short-term
bedrest, and the insertion site extremity should be kept straight. The nurse should
assess the site for bloody drainage or hematoma formation because complications with
vascular closure devices are not common but can be very serious.
A middle-aged man is admitted to the cardiac unit after reports of a severe headache
and flushing of the face. He is diagnosed with severe hypertension. The patient is alert
and oriented. BP = 192/104, HR = 88. You are the RN assigned to his care. There is an
unlicensed nurse technician working with you.
1. What assessment data will you perform upon his arrival to the unit? why?
2. The cardiologist prescribes IV fluids, hourly BP checks, BP medication, and oxygen
at 2 L/min via nasal cannula. What part of the patient's care will you delegate to the
unlicensed nurse technician? What information will you communicate upon delegation?
QUESTIONS WITH CORRECT
ANSWERS
A client is diagnosed with left-sided heart failure. Which assessment findings will the
nurse expect the client to have? Select all that apply.
A. Peripheral edema
B. Crackles in both lungs
C. Breathlessness
D. Ascites
E. Tachypnea - Answer- B. crackles in both lungs, C. breathlessness, E. tachypnea
Rationale: Clients with left-sided heart failure will exhibit symptoms such as fatigue,
dyspnea, or breathlessness, and crackles on auscultation of breath sounds. Peripheral
edema and ascites are associated with right-sided heart failure.
A client has been taking furosemide (Lasix) and valsartan (Diovan) for the past year.
The hospital laboratory notifies the nurse that the client's serum potassium level is 6.2
mEq/L. What is the nurse's best action at this time?
A. Assess the client's oxygen saturation level
B. Ask the laboratory to retest the potassium level
C. Give potassium as an IV insertion
D. Check the client's serum creatinine - Answer- D. Check the client's serum creatinine.
Rationale: Clients who are hyperkalemic may also be in renal failure. The client's serum
creatinine should be reviewed to determine if it is greater than 1.8 mg/dL, at which time
the health care provider should be notified before administering any supplemental
potassium.
An older adult taking digoxin and hydrochlorothiazide (HCTZ) for chronic heart failure is
admitted to the ED with an apical pulse of 48. A family member states that the client has
reported blurred vision and loss of appetite for 2 weeks. What is the nurse's first action?
A. Call the ED physician immediately
B. Draw a serum digoxin level
C. Assess for signs of hypokalemia
D. Establish the client's airway - Answer- B. Draw a serum digoxin level
Rationale: The clinical manifestations of digoxin toxicity are often vague and nonspecific
and include anorexia, fatigue, blurred vision, and changes in mental status, especially in
, older adults. Older adults are more likely than other patients to become toxic because of
decreased renal excretion.
A client who recently had a heart valve replacement is taking warfarin (Coumadin) as
prescribed. What statement by the client indicates that the nurse will need to do
additional health teaching?
A. "I will take my pulse every day, and call my doctor if it is below 60"
B. "I will eat foods that are high in vitamin K, such as kale and spinach"
C. "I will weigh myself every day in the morning using the same scale"
D. "I will take my blood pressure everyday and call if it is too high or low" - Answer- B. "I
will eat foods that are high in vitamin K, such as kale and spinach"
Rationale: pt should be taught to avoid foods that are high in vitamin K, as well as herbs
such as ginger, ginseng, goldenseal, Gingko biloba, and St. John's wort because all of
these may interfere with the drug's action; spinach and kale are high in vitamin K
The nurse is providing education to help reduce cardiovascular risks for a women's
book club. Which statement made by a participant indicates a need for further teaching?
a. "We are more likely to die from cardiovascular disease than men"
b. "We need to walk or do other exercise everyday for 30 minutes"
c. "We need to stay away from people who smoke"
d. "We should take hormones for menopause to decrease the risk for heart attack" -
Answer- d. "We should take hormones for menopause to decrease the risk for heart
attack"
Rationale: meds used in hormone therapy can cause an increased incidence of MI or
stroke in women
A client is admitted to the telemetry unit after a right-sided cardiac catheterization. What
is the nurse's priority when caring for this client?
a. Assess the intensity and quality of the client's pain
b. Position the client in a sitting position to improve breathing
c. Check the client's arterial insertion site
d. Apply oxygen at 2 L/min via nasal cannula - Answer- c. Check the client's arterial
insertion site
Rationale: Pts who have had a cardiac catheterization should be restricted to short-term
bedrest, and the insertion site extremity should be kept straight. The nurse should
assess the site for bloody drainage or hematoma formation because complications with
vascular closure devices are not common but can be very serious.
A middle-aged man is admitted to the cardiac unit after reports of a severe headache
and flushing of the face. He is diagnosed with severe hypertension. The patient is alert
and oriented. BP = 192/104, HR = 88. You are the RN assigned to his care. There is an
unlicensed nurse technician working with you.
1. What assessment data will you perform upon his arrival to the unit? why?
2. The cardiologist prescribes IV fluids, hourly BP checks, BP medication, and oxygen
at 2 L/min via nasal cannula. What part of the patient's care will you delegate to the
unlicensed nurse technician? What information will you communicate upon delegation?
