Heart Failure NCLEX Review Questions with 100% Verified Answers
1. The nurse is administering a D. Anorexia and nausea
dose of digoxin (Lanoxin) to a pa-
tient with heart failure (HF). The Anorexia, nausea, vomiting, blurred or
nurse would become concerned yellow vision, and cardiac dysrhythmias
with the possibility of digitalis are all signs of digitalis toxicity. The nurse
toxicity if the patient reported would become concerned and notify the
which symptom(s)? health care provider if the patient exhib-
ited any of these symptoms.
A. Muscle aches
B. Constipation
C. Pounding headache
D. Anorexia and nausea
2. The nurse is preparing to admin- B. Withhold the dose and report the
ister digoxin to a patient with potassium level.
heart failure. In preparation, lab-
oratory results are reviewed with The normal potassium level is 3.5 to
the following findings: sodium 5.0 mEq/L. The patient is hyperkalemic,
139 mEq/L, potassium 5.6 mEq/L, which makes the patient more prone to
chloride 103 mEq/L, and glu- digoxin toxicity. For this reason, the nurse
cose 106 mg/dL. What should the should withhold the dose and report the
nurse do next? potassium level. The physician may or-
der the digoxin to be given once the
A. Withhold the daily dose until potassium level has been treated and
the following day. decreases to within normal range.
B. Withhold the dose and report
the potassium level.
C. Give the digoxin with a salty
snack, such as crackers.
D. Give the digoxin with extra flu-
ids to dilute the sodium level.
3. What is the priority assessment C. Blood pressure
by the nurse caring for a patient
receiving IV nesiritide (Natrecor) Although all identified assessments are
to treat heart failure? appropriate for a patient receiving IV ne-
siritide, the priority assessment would be
A. Urine output monitoring for hypotension, the main ad-
B. Lung sounds verse effect of nesiritide.
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, Heart Failure NCLEX Review Questions with 100% Verified Answers
C. Blood pressure
D. Respiratory rate
4. A patient admitted with heart fail- A, B, D, E.
ure appears very anxious and
complains of shortness of breath. Morphine sulfate reduces anxiety and
Which nursing actions would be may assist in reducing dyspnea.
appropriate to alleviate this pa- The patient should be positioned in
tient's anxiety (select all that ap- semi-Fowler's position to improve venti-
ply)? lation that will reduce anxiety. Relaxation
techniques and a calm reassuring ap-
A. Administer ordered morphine proach will also serve to reduce anxiety.
sulfate.
B. Position patient in a
semi-Fowler's position.
C. Position patient on left side
with head of bed flat.
D. Instruct patient on the use of
relaxation techniques.
E. Use a calm, reassuring ap-
proach while talking to patient.
5. A male patient with a long-stand- D. Choose interventions to promote com-
ing history of heart failure has re- fort and prevent suffering.
cently qualified for hospice care.
What measure should the nurse The central focus of hospice care is the
now prioritize when providing promotion of comfort and the prevention
care for this patient? of suffering. Patient education should
continue, but providing comfort is para-
A. Taper the patient off his current mount. Medications should be continued
medications. unless they are not tolerated. Experi-
B. Continue education for the pa- mental therapies and surgeries are not
tient and his family. commonly used in the care of hospice
C. Pursue experimental therapies patients.
or surgical options.
D. Choose interventions to pro-
mote comfort and prevent suffer-
ing.
2/7
1. The nurse is administering a D. Anorexia and nausea
dose of digoxin (Lanoxin) to a pa-
tient with heart failure (HF). The Anorexia, nausea, vomiting, blurred or
nurse would become concerned yellow vision, and cardiac dysrhythmias
with the possibility of digitalis are all signs of digitalis toxicity. The nurse
toxicity if the patient reported would become concerned and notify the
which symptom(s)? health care provider if the patient exhib-
ited any of these symptoms.
A. Muscle aches
B. Constipation
C. Pounding headache
D. Anorexia and nausea
2. The nurse is preparing to admin- B. Withhold the dose and report the
ister digoxin to a patient with potassium level.
heart failure. In preparation, lab-
oratory results are reviewed with The normal potassium level is 3.5 to
the following findings: sodium 5.0 mEq/L. The patient is hyperkalemic,
139 mEq/L, potassium 5.6 mEq/L, which makes the patient more prone to
chloride 103 mEq/L, and glu- digoxin toxicity. For this reason, the nurse
cose 106 mg/dL. What should the should withhold the dose and report the
nurse do next? potassium level. The physician may or-
der the digoxin to be given once the
A. Withhold the daily dose until potassium level has been treated and
the following day. decreases to within normal range.
B. Withhold the dose and report
the potassium level.
C. Give the digoxin with a salty
snack, such as crackers.
D. Give the digoxin with extra flu-
ids to dilute the sodium level.
3. What is the priority assessment C. Blood pressure
by the nurse caring for a patient
receiving IV nesiritide (Natrecor) Although all identified assessments are
to treat heart failure? appropriate for a patient receiving IV ne-
siritide, the priority assessment would be
A. Urine output monitoring for hypotension, the main ad-
B. Lung sounds verse effect of nesiritide.
1/7
, Heart Failure NCLEX Review Questions with 100% Verified Answers
C. Blood pressure
D. Respiratory rate
4. A patient admitted with heart fail- A, B, D, E.
ure appears very anxious and
complains of shortness of breath. Morphine sulfate reduces anxiety and
Which nursing actions would be may assist in reducing dyspnea.
appropriate to alleviate this pa- The patient should be positioned in
tient's anxiety (select all that ap- semi-Fowler's position to improve venti-
ply)? lation that will reduce anxiety. Relaxation
techniques and a calm reassuring ap-
A. Administer ordered morphine proach will also serve to reduce anxiety.
sulfate.
B. Position patient in a
semi-Fowler's position.
C. Position patient on left side
with head of bed flat.
D. Instruct patient on the use of
relaxation techniques.
E. Use a calm, reassuring ap-
proach while talking to patient.
5. A male patient with a long-stand- D. Choose interventions to promote com-
ing history of heart failure has re- fort and prevent suffering.
cently qualified for hospice care.
What measure should the nurse The central focus of hospice care is the
now prioritize when providing promotion of comfort and the prevention
care for this patient? of suffering. Patient education should
continue, but providing comfort is para-
A. Taper the patient off his current mount. Medications should be continued
medications. unless they are not tolerated. Experi-
B. Continue education for the pa- mental therapies and surgeries are not
tient and his family. commonly used in the care of hospice
C. Pursue experimental therapies patients.
or surgical options.
D. Choose interventions to pro-
mote comfort and prevent suffer-
ing.
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