ATI MED SURG: Heart Failure NCLEX Practice Study Guide
Questions with A level solution version 2025/2026
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 answer D. Blood pressure
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.
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.
B. Controlling dysrhythmias will eliminate HF.
C. Prescription for digoxin (Lanoxin) at discharge
D. Prescription for angiotensin-converting enzyme (ACE) inhibitor at discharge
E. Education materials about activity, medications, weight monitoring, and what to do if
symptoms worsen - correct answer A, D, E.
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.
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 answer D. Right-sided HF
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.
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 answer D. Cardiac vasculopathy
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.
Questions with A level solution version 2025/2026
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 answer D. Blood pressure
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.
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.
B. Controlling dysrhythmias will eliminate HF.
C. Prescription for digoxin (Lanoxin) at discharge
D. Prescription for angiotensin-converting enzyme (ACE) inhibitor at discharge
E. Education materials about activity, medications, weight monitoring, and what to do if
symptoms worsen - correct answer A, D, E.
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.
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 answer D. Right-sided HF
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.
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 answer D. Cardiac vasculopathy
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.
