2025 A&E II Exam 2 with 340 questions
with complete solutions.
2025 A&E II Exam 2 with 340 questions
with complete solutions.
The home care nurse visits a patient with chronic heart failure who is taking digoxin and furosemide. The
patient complains of nausea and vomiting. Which action is most appropriate for the nurse to take?
A:Perform a dipstick urine test for protein.
B:Notify the health care provider immediately.
C: Have the patient eat foods high in potassium.
D:Ask the patient to record a weight every morning. - ANSWER B: Notify the health care provider
immediately.
A patient with left-sided heart failure is prescribed oxygen at 4 L/min per nasal cannula, furosemide,
spironolactone, and enalapril. Which assessment should the nurse complete to best evaluate the
patient's response to these drugs?
A: Observe skin turgor
B: Auscultate lung sounds
C: Measure blood pressure
D: Review intake and output - ANSWER B: Auscultate lung sounds
Left = Lungs
While assessing a 68-year-old with ascites, the nurse also notes jugular venous distention (JVD) with the
head of the patient's bed elevated 45 degrees. The nurse knows this finding indicates
a.decreased fluid volume.
b.jugular vein atherosclerosis.
,2025 A&E II Exam 2 with 340 questions
with complete solutions.
c.increased right atrial pressure.
d.incompetent jugular vein valves. - ANSWER c.increased right atrial pressure.
The jugular veins empty into the superior vena cava and then into the right atrium, so JVD with the
patient sitting at a 45-degree angle reflects increased right atrial pressure.
JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid volume. JVD is not
caused by incompetent jugular vein valves or atherosclerosis.
The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment
of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best
indicator that the treatment has been effective?
a.Weight loss of 2 pounds in 24 hours
b.Hourly urine output greater than 60 mL
c.Reduction in patient complaints of chest pain
d.Reduced dyspnea with the head of bed at 30 degrees - ANSWER d.Reduced dyspnea with the head of
bed at 30 degrees
Because the patient's major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid
in the alveoli), the best indicator that the medications are effective is a decrease in dyspnea with the
head of the bed at 30 degrees. The other assessment data also may indicate that diuresis or
improvement in cardiac output has occurred, but are not as specific to evaluating this patient's
response.
Which topic will the nurse plan to include in discharge teaching for a patient with systolic heart failure
and an ejection fraction of 33%?
a.Need to begin an aerobic exercise program several times weekly
b.Use of salt substitutes to replace table salt when cooking and at the table
c.Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors
,2025 A&E II Exam 2 with 340 questions
with complete solutions.
d.Importance of making an annual appointment with the primary care provider - ANSWER c.Benefits and
side effects of angiotensin-converting enzyme (ACE) inhibitors
The core measures for the treatment of heart failure established by The Joint Commission indicate that
patients with an ejection fraction (EF) <40% receive an ACE inhibitor to decrease the progression of
heart failure.
Aerobic exercise may not be appropriate for a patient with this level of heart failure, salt substitutes are
not usually recommended because of the risk of hyperkalemia, and the patient will need to see the
primary care provider more frequently than annually.
IV sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first
hours of administration, the nurse will need to titrate the nitroprusside rate if the patient develops
a.ventricular ectopy.
b.a dry, hacking cough.
c.a systolic BP <90 mm Hg.
d.a heart rate <50 beats/minute. - ANSWER c.a systolic BP <90 mm Hg.
Sodium nitroprusside is a potent vasodilator, and the major adverse effect is severe hypotension.
Coughing and bradycardia are not adverse effects of this medication. Nitroprusside does not cause
increased ventricular ectopy.
A patient who has chronic heart failure tells the nurse, "I was fine when I went to bed, but I woke up in
the middle of the night feeling like I was suffocating!" The nurse will document this assessment finding
as
a.orthopnea.
b.pulsus alternans.
c.paroxysmal nocturnal dyspnea.
, 2025 A&E II Exam 2 with 340 questions
with complete solutions.
d.acute bilateral pleural effusion. - ANSWER c.paroxysmal nocturnal dyspnea.
Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from dependent body areas when
the patient is sleeping and is characterized by waking up suddenly with the feeling of suffocation. Pulsus
alternansis the alternation of strong and weak peripheral pulses during palpation. Orthopnea indicates
that the patient is unable to lie flat because of dyspnea. Pleural effusions develop over a longer time
period.
During a visit to a 78-year-old with chronic heart failure, the home care nurse finds that the patient has
ankle edema, a 2-kg weight gain over the past 2 days, and complains of "feeling too tired to get out of
bed." Based on these data, the best nursing diagnosis for the patient is
a.activity intolerance related to fatigue.
b.disturbed body image related to weight gain.
c.impaired skin integrity related to ankle edema.
d.impaired gas exchange related to dyspnea on exertion. - ANSWER a.activity intolerance related to
fatigue.
The patient's statement supports the diagnosis of activity intolerance. There are no data to support the
other diagnoses, although the nurse will need to assess for other patient problems.
The nurse working on the heart failure unit knows that teaching an older female patient with newly
diagnosed heart failure is effective when the patient states that
a.she will take furosemide (Lasix) every day at bedtime.
b.the nitroglycerin patch is applied when any chest pain develops.
c.she will call the clinic if her weight goes from 124 to 128 pounds in a week.
d.an additional pillow can help her sleep if she is feeling short of breath at night. - ANSWER c.she will call
the clinic if her weight goes from 124 to 128 pounds in a week.
with complete solutions.
2025 A&E II Exam 2 with 340 questions
with complete solutions.
The home care nurse visits a patient with chronic heart failure who is taking digoxin and furosemide. The
patient complains of nausea and vomiting. Which action is most appropriate for the nurse to take?
A:Perform a dipstick urine test for protein.
B:Notify the health care provider immediately.
C: Have the patient eat foods high in potassium.
D:Ask the patient to record a weight every morning. - ANSWER B: Notify the health care provider
immediately.
A patient with left-sided heart failure is prescribed oxygen at 4 L/min per nasal cannula, furosemide,
spironolactone, and enalapril. Which assessment should the nurse complete to best evaluate the
patient's response to these drugs?
A: Observe skin turgor
B: Auscultate lung sounds
C: Measure blood pressure
D: Review intake and output - ANSWER B: Auscultate lung sounds
Left = Lungs
While assessing a 68-year-old with ascites, the nurse also notes jugular venous distention (JVD) with the
head of the patient's bed elevated 45 degrees. The nurse knows this finding indicates
a.decreased fluid volume.
b.jugular vein atherosclerosis.
,2025 A&E II Exam 2 with 340 questions
with complete solutions.
c.increased right atrial pressure.
d.incompetent jugular vein valves. - ANSWER c.increased right atrial pressure.
The jugular veins empty into the superior vena cava and then into the right atrium, so JVD with the
patient sitting at a 45-degree angle reflects increased right atrial pressure.
JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid volume. JVD is not
caused by incompetent jugular vein valves or atherosclerosis.
The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment
of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best
indicator that the treatment has been effective?
a.Weight loss of 2 pounds in 24 hours
b.Hourly urine output greater than 60 mL
c.Reduction in patient complaints of chest pain
d.Reduced dyspnea with the head of bed at 30 degrees - ANSWER d.Reduced dyspnea with the head of
bed at 30 degrees
Because the patient's major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid
in the alveoli), the best indicator that the medications are effective is a decrease in dyspnea with the
head of the bed at 30 degrees. The other assessment data also may indicate that diuresis or
improvement in cardiac output has occurred, but are not as specific to evaluating this patient's
response.
Which topic will the nurse plan to include in discharge teaching for a patient with systolic heart failure
and an ejection fraction of 33%?
a.Need to begin an aerobic exercise program several times weekly
b.Use of salt substitutes to replace table salt when cooking and at the table
c.Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors
,2025 A&E II Exam 2 with 340 questions
with complete solutions.
d.Importance of making an annual appointment with the primary care provider - ANSWER c.Benefits and
side effects of angiotensin-converting enzyme (ACE) inhibitors
The core measures for the treatment of heart failure established by The Joint Commission indicate that
patients with an ejection fraction (EF) <40% receive an ACE inhibitor to decrease the progression of
heart failure.
Aerobic exercise may not be appropriate for a patient with this level of heart failure, salt substitutes are
not usually recommended because of the risk of hyperkalemia, and the patient will need to see the
primary care provider more frequently than annually.
IV sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first
hours of administration, the nurse will need to titrate the nitroprusside rate if the patient develops
a.ventricular ectopy.
b.a dry, hacking cough.
c.a systolic BP <90 mm Hg.
d.a heart rate <50 beats/minute. - ANSWER c.a systolic BP <90 mm Hg.
Sodium nitroprusside is a potent vasodilator, and the major adverse effect is severe hypotension.
Coughing and bradycardia are not adverse effects of this medication. Nitroprusside does not cause
increased ventricular ectopy.
A patient who has chronic heart failure tells the nurse, "I was fine when I went to bed, but I woke up in
the middle of the night feeling like I was suffocating!" The nurse will document this assessment finding
as
a.orthopnea.
b.pulsus alternans.
c.paroxysmal nocturnal dyspnea.
, 2025 A&E II Exam 2 with 340 questions
with complete solutions.
d.acute bilateral pleural effusion. - ANSWER c.paroxysmal nocturnal dyspnea.
Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from dependent body areas when
the patient is sleeping and is characterized by waking up suddenly with the feeling of suffocation. Pulsus
alternansis the alternation of strong and weak peripheral pulses during palpation. Orthopnea indicates
that the patient is unable to lie flat because of dyspnea. Pleural effusions develop over a longer time
period.
During a visit to a 78-year-old with chronic heart failure, the home care nurse finds that the patient has
ankle edema, a 2-kg weight gain over the past 2 days, and complains of "feeling too tired to get out of
bed." Based on these data, the best nursing diagnosis for the patient is
a.activity intolerance related to fatigue.
b.disturbed body image related to weight gain.
c.impaired skin integrity related to ankle edema.
d.impaired gas exchange related to dyspnea on exertion. - ANSWER a.activity intolerance related to
fatigue.
The patient's statement supports the diagnosis of activity intolerance. There are no data to support the
other diagnoses, although the nurse will need to assess for other patient problems.
The nurse working on the heart failure unit knows that teaching an older female patient with newly
diagnosed heart failure is effective when the patient states that
a.she will take furosemide (Lasix) every day at bedtime.
b.the nitroglycerin patch is applied when any chest pain develops.
c.she will call the clinic if her weight goes from 124 to 128 pounds in a week.
d.an additional pillow can help her sleep if she is feeling short of breath at night. - ANSWER c.she will call
the clinic if her weight goes from 124 to 128 pounds in a week.
