NUR 430 Exam 1 NCLEX Questions With
Complete Answers
Nutritional intervention in heart failure is aimed at a reduction in fluid retention
and sodium limitation in order to:
A) increase central venous pressure.
B) increase end-diastolic volume.
C) reduce afterload.
D) reduce preload. - ANSWER D) reduce preload
Interventions in heart failure are designed to reduce fluid retention, thereby
reducing the preload.
Anorexia may interfere with oral intake. Patients who are unable to meet their
caloric needs on their own require nutritional intervention. Which of the
following statements best describes the goal of initiating a nutritional
intervention for a patient with anorexia?
A) Diarrhea from concurrent administration of lactulose coincides with feeding
intolerance.
B) Small, frequent feedings are usually tolerated less than are three regular
meals daily.
C) Standard nasogastric feeding tubes can be used safely without increasing
the risk of variceal bleeding.
D) Total parenteral nutrition (TPN) should be reserved for patients who are
absolutely unable to tolerate oral and enteral feeding. - ANSWER D) Total
parenteral nutrition (TPN) should be reserved for patients who are absolutely
unable to tolerate oral and enteral feeding.
Small-bore nasoenteric feeding tubes can be used safely without increasing the
risk of variceal bleeding. TPN should be reserved for patients who are
absolutely unable to tolerate enteral feeding. Diarrhea from concurrent
administration of lactulose should not be confused with feeding intolerance.
A patient with facial trauma is unable to eat after surgery. His albumin level is
1.5. He is probably in a:
A) Positive nitrogen balance
B) Negative nitrogen balance
C) Nitrogen equilibrium
D) Nitrogen disequilibrium - ANSWER B) Negative nitrogen balance
,The patient is experiencing a high rate of gluconeogenesis and is burning up his
protein stores. Muscle mass will break down unless nutrition is given. A positive
nitrogen balance means the patient is eating more than he is excreting (healing).
Nitrogen equilibrium occurs in normal, healthy adults. Nitrogen disequilibrium is
a nonexistent condition.
A patient has low albumin, prealbumin, and transferrin levels with a decreased
total lymphocyte count. The priority nursing diagnosis is:
A) Altered Nutrition, Less Than Body Requirement
B) Risk for Infection
C) Fluid Volume Overload
D) Altered Nutrition, More Than Body Requirement - ANSWER A) Altered
Nutrition, Less Than Body Requirement
In this case, the patient is showing signs of malnutrition and protein deficiency
that must be corrected. There is a risk for infection, but an actual problem is
more of a priority than a potential one. The patient would have a fluid volume
deficit, not an overload. Cognitive Level: Synthesis Nursing Process: Planning
Client Need: Physiological Integrity: Physiological Adaptation
The nurse is providing dietary education for the patient with hypertension. The
patient asks what the DASH diet is. Which of the following comments is
appropriate for the nurse to make?
A) "DASH refers to the salt-free spices you should learn to cook with now."
B) "DASH stands for dietary approach to stop hypertension."
C) "It means you must eliminate all salt from your diet."
D) "The DASH diet eliminates fruits from the diet." - ANSWER B) "DASH stands
for dietary approach to stop hypertension."
Dietary Approach to Stop Hypertension is the correct definition for DASH. The
object is to consume a diet rich in fruits and vegetables, potassium, and calcium
and low in saturated fat to help control hypertension. The DASH diet does not
refer to salt-free spices. One cannot eliminate all salt from the diet, but lower
salt is advisable for those sensitive to increased salt levels. The DASH diet is
high in both fruits and vegetables. Cognitive Level: Comprehension Nursing
Process: Implementation Client Need: Health Promotion and Maintenance
Nutritional intervention in heart failure is aimed at a reduction in fluid retention
and sodium limitation in order to:
A) reduce afterload.
B) reduce preload.
C) increase end-diastolic volume.
D) increase central venous pressure. - ANSWER B) reduce preload.
Interventions in heart failure are designed to reduce fluid retention, thereby
reducing the preload.
,A patient is receiving enteral nutritional feeding. Which intervention should be
included to reduce the risk of aspiration?
A) Maintain head of bed at less than 30 degrees.
B) Deflate the endotracheal tube cuff during feeding administration.
C) Feed into the small bowel rather than the stomach.
D) Hold feedings for gastric residual volume of 50 mL. - ANSWER C) Feed into
the small bowel rather than the stomach.
Pulmonary aspiration of enteral formulas and subsequent pneumonia is a
serious complication of enteral feeding in critically ill patients. To reduce the
risk of pulmonary aspiration of formula during enteral feeding, the nurse must
keep the head of the bed elevated unless contraindicated; temporarily stop
feedings when the patient must be supine for prolonged periods; position the
patient in the right lateral decubitus position when possible to encourage gastric
emptying; use postpyloric feeding methods; keep the cuff of the endotracheal
tube inflated as much as possible during enteral feeding, if applicable; and be
alert to any increase in abdominal distention. Except in selected high-risk
patients, there is little evidence to support holding tube feedings in patients with
gastric residual volumes less than 400 mL.
When a papillary muscle in the left ventricle ruptures, the mitral valve leaflets do
not close completely, resulting in:
A) acute myocardial infarction.
B) aortic valve failure.
C) cardiac murmur.
D) systemic venous congestion. - ANSWER C) cardiac murmur.
A dysfunction of the chordae tendineae or of a papillary muscle can cause
incomplete closure of an atrioventricular valve, which results in backflow of
blood into the atrium and produces a murmur. If a papillary muscle in the left
ventricle ruptures, the mitral valve leaflets do not close completely. Clinically,
this causes acute mitral regurgitation and an audible murmur that can be
auscultated with a stethoscope.
Aortic valve dysfunction pathologically alters the:
A) left atrium.
B) left ventricle.
C) right ventricle.
D) mitral valve. - ANSWER B) left ventricle.
Aortic valve dysfunction from any cause not only affects the valve leaflets but
also pathologically alters the shape of the left ventricle.
, A physiologic cardiac shunt occurs when there is mixing of deoxygenated blood
(usually venous blood with reduced oxygen content) with arterial oxygenated
blood. In the heart, this is demonstrated by:
A) atrial septal defect.
B) patent foramen ovale.
C) thebesian veins.
D) ventricular septal defect. - ANSWER C) thebesian veins.
The thebesian veins are small vessels that connect capillary beds directly with
the cardiac chambers via irregular endothelium-lined sinuses within the
myocardium. The thebesian veins add a small quantity of deoxygenated blood to
the oxygenated blood in the left ventricle.
An important intracellular structure, essential for cardiac contraction, that
stores calcium ions for release and use after depolarization is the:
A) sarcoplasmic reticulum.
B) sarcomere.
C) sarcolemma.
D) transverse tubules. - ANSWER A) sarcoplasmic reticulum.
An extremely important intracellular structure that is necessary for successful
contraction is the sarcoplasmic reticulum. Calcium ions are stored in the
sarcoplasmic reticulum and released for use after depolarization.
The time from the beginning of the cardiac action potential (AP) until the time
when the fiber can accept another AP is called the:
A) excitability period.
B) depolarization period.
C) relative refractory period.
D) absolute refractory period. - ANSWER D) absolute refractory period.
The time from the beginning of the AP until the fiber can accept another AP is
called the effective or absolute refractory period. During this period, the cell
cannot be depolarized regardless of the amount or intensity of the stimulus.
The nurse auscultates a murmur at the fifth intercostal space at the
midclavicular line on the left side. The nurse realizes that this is caused by which
incompetent heart valve?
A) Aortic
B) Pulmonic
C) Mitral
D) Tricuspid - ANSWER C) Mitral
This is the correct location of the mitral valve. The aortic valve is located at the
second right intercostal space at the right sternal border. The pulmonic valve is
located at the second left intercostal space at the left sternal border. The
Complete Answers
Nutritional intervention in heart failure is aimed at a reduction in fluid retention
and sodium limitation in order to:
A) increase central venous pressure.
B) increase end-diastolic volume.
C) reduce afterload.
D) reduce preload. - ANSWER D) reduce preload
Interventions in heart failure are designed to reduce fluid retention, thereby
reducing the preload.
Anorexia may interfere with oral intake. Patients who are unable to meet their
caloric needs on their own require nutritional intervention. Which of the
following statements best describes the goal of initiating a nutritional
intervention for a patient with anorexia?
A) Diarrhea from concurrent administration of lactulose coincides with feeding
intolerance.
B) Small, frequent feedings are usually tolerated less than are three regular
meals daily.
C) Standard nasogastric feeding tubes can be used safely without increasing
the risk of variceal bleeding.
D) Total parenteral nutrition (TPN) should be reserved for patients who are
absolutely unable to tolerate oral and enteral feeding. - ANSWER D) Total
parenteral nutrition (TPN) should be reserved for patients who are absolutely
unable to tolerate oral and enteral feeding.
Small-bore nasoenteric feeding tubes can be used safely without increasing the
risk of variceal bleeding. TPN should be reserved for patients who are
absolutely unable to tolerate enteral feeding. Diarrhea from concurrent
administration of lactulose should not be confused with feeding intolerance.
A patient with facial trauma is unable to eat after surgery. His albumin level is
1.5. He is probably in a:
A) Positive nitrogen balance
B) Negative nitrogen balance
C) Nitrogen equilibrium
D) Nitrogen disequilibrium - ANSWER B) Negative nitrogen balance
,The patient is experiencing a high rate of gluconeogenesis and is burning up his
protein stores. Muscle mass will break down unless nutrition is given. A positive
nitrogen balance means the patient is eating more than he is excreting (healing).
Nitrogen equilibrium occurs in normal, healthy adults. Nitrogen disequilibrium is
a nonexistent condition.
A patient has low albumin, prealbumin, and transferrin levels with a decreased
total lymphocyte count. The priority nursing diagnosis is:
A) Altered Nutrition, Less Than Body Requirement
B) Risk for Infection
C) Fluid Volume Overload
D) Altered Nutrition, More Than Body Requirement - ANSWER A) Altered
Nutrition, Less Than Body Requirement
In this case, the patient is showing signs of malnutrition and protein deficiency
that must be corrected. There is a risk for infection, but an actual problem is
more of a priority than a potential one. The patient would have a fluid volume
deficit, not an overload. Cognitive Level: Synthesis Nursing Process: Planning
Client Need: Physiological Integrity: Physiological Adaptation
The nurse is providing dietary education for the patient with hypertension. The
patient asks what the DASH diet is. Which of the following comments is
appropriate for the nurse to make?
A) "DASH refers to the salt-free spices you should learn to cook with now."
B) "DASH stands for dietary approach to stop hypertension."
C) "It means you must eliminate all salt from your diet."
D) "The DASH diet eliminates fruits from the diet." - ANSWER B) "DASH stands
for dietary approach to stop hypertension."
Dietary Approach to Stop Hypertension is the correct definition for DASH. The
object is to consume a diet rich in fruits and vegetables, potassium, and calcium
and low in saturated fat to help control hypertension. The DASH diet does not
refer to salt-free spices. One cannot eliminate all salt from the diet, but lower
salt is advisable for those sensitive to increased salt levels. The DASH diet is
high in both fruits and vegetables. Cognitive Level: Comprehension Nursing
Process: Implementation Client Need: Health Promotion and Maintenance
Nutritional intervention in heart failure is aimed at a reduction in fluid retention
and sodium limitation in order to:
A) reduce afterload.
B) reduce preload.
C) increase end-diastolic volume.
D) increase central venous pressure. - ANSWER B) reduce preload.
Interventions in heart failure are designed to reduce fluid retention, thereby
reducing the preload.
,A patient is receiving enteral nutritional feeding. Which intervention should be
included to reduce the risk of aspiration?
A) Maintain head of bed at less than 30 degrees.
B) Deflate the endotracheal tube cuff during feeding administration.
C) Feed into the small bowel rather than the stomach.
D) Hold feedings for gastric residual volume of 50 mL. - ANSWER C) Feed into
the small bowel rather than the stomach.
Pulmonary aspiration of enteral formulas and subsequent pneumonia is a
serious complication of enteral feeding in critically ill patients. To reduce the
risk of pulmonary aspiration of formula during enteral feeding, the nurse must
keep the head of the bed elevated unless contraindicated; temporarily stop
feedings when the patient must be supine for prolonged periods; position the
patient in the right lateral decubitus position when possible to encourage gastric
emptying; use postpyloric feeding methods; keep the cuff of the endotracheal
tube inflated as much as possible during enteral feeding, if applicable; and be
alert to any increase in abdominal distention. Except in selected high-risk
patients, there is little evidence to support holding tube feedings in patients with
gastric residual volumes less than 400 mL.
When a papillary muscle in the left ventricle ruptures, the mitral valve leaflets do
not close completely, resulting in:
A) acute myocardial infarction.
B) aortic valve failure.
C) cardiac murmur.
D) systemic venous congestion. - ANSWER C) cardiac murmur.
A dysfunction of the chordae tendineae or of a papillary muscle can cause
incomplete closure of an atrioventricular valve, which results in backflow of
blood into the atrium and produces a murmur. If a papillary muscle in the left
ventricle ruptures, the mitral valve leaflets do not close completely. Clinically,
this causes acute mitral regurgitation and an audible murmur that can be
auscultated with a stethoscope.
Aortic valve dysfunction pathologically alters the:
A) left atrium.
B) left ventricle.
C) right ventricle.
D) mitral valve. - ANSWER B) left ventricle.
Aortic valve dysfunction from any cause not only affects the valve leaflets but
also pathologically alters the shape of the left ventricle.
, A physiologic cardiac shunt occurs when there is mixing of deoxygenated blood
(usually venous blood with reduced oxygen content) with arterial oxygenated
blood. In the heart, this is demonstrated by:
A) atrial septal defect.
B) patent foramen ovale.
C) thebesian veins.
D) ventricular septal defect. - ANSWER C) thebesian veins.
The thebesian veins are small vessels that connect capillary beds directly with
the cardiac chambers via irregular endothelium-lined sinuses within the
myocardium. The thebesian veins add a small quantity of deoxygenated blood to
the oxygenated blood in the left ventricle.
An important intracellular structure, essential for cardiac contraction, that
stores calcium ions for release and use after depolarization is the:
A) sarcoplasmic reticulum.
B) sarcomere.
C) sarcolemma.
D) transverse tubules. - ANSWER A) sarcoplasmic reticulum.
An extremely important intracellular structure that is necessary for successful
contraction is the sarcoplasmic reticulum. Calcium ions are stored in the
sarcoplasmic reticulum and released for use after depolarization.
The time from the beginning of the cardiac action potential (AP) until the time
when the fiber can accept another AP is called the:
A) excitability period.
B) depolarization period.
C) relative refractory period.
D) absolute refractory period. - ANSWER D) absolute refractory period.
The time from the beginning of the AP until the fiber can accept another AP is
called the effective or absolute refractory period. During this period, the cell
cannot be depolarized regardless of the amount or intensity of the stimulus.
The nurse auscultates a murmur at the fifth intercostal space at the
midclavicular line on the left side. The nurse realizes that this is caused by which
incompetent heart valve?
A) Aortic
B) Pulmonic
C) Mitral
D) Tricuspid - ANSWER C) Mitral
This is the correct location of the mitral valve. The aortic valve is located at the
second right intercostal space at the right sternal border. The pulmonic valve is
located at the second left intercostal space at the left sternal border. The
