MED-SURG SUCCESS DAVIS – CARDIAC
QUESTIONS WITH ACTUAL
SOLUTIONS.
The client is admitted to the telemetry unit diagnosed with acute exacerbation of
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congestive heart failure (CHF). Which signs/symptoms would the nurse expect to find
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when assessing this client?
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1. Apical pulse rate of 110 and 4+ pitting edema of feet.
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2. Thick white sputum and crackles that clear with cough.
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3. The client sleeping with no pillow and eupnea.
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4. Radial pulse rate of 90 and capillary refill time <3 seconds. - ANSWER: 1. Apical pulse rate
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of 110 and 4+ pitting edema of feet.
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1. The client with CHF would exhibit
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tachycardia (apical pulse rate of 110), bb bb bb bb bb
dependent edema, fatigue, third heart bb bb bb bb
sounds, lung congestion, and change in bb bb bb bb bb
mental status. bb
2. The client with CHF usually has pink
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frothy sputum and crackles that do not clear
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with coughing. bb
3. The client with CHF would report sleeping
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on at least two pillows, if not sleeping in an
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,upright position, and labored breathing, not
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eupnea, which means normal breathing. bb bb bb bb
4. In a client diagnosed with heart failure, the
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apical pulse, not the radial pulse, is the best
bb bb bb bb bb bb bb bb
place to assess the cardiac status.
bb bb bb bb bb
TEST-TAKING HINT: In option "3," the word bb bb bb bb bb bb
"no" is an absolute term, and usually
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absolutes, such as "no," "never," "always," bb bb bb bb bb
and "only," are incorrect because there is
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no room for any other possible answer. If
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the test taker is looking for abnormal data,
bb bb bb bb bb bb bb
then the test taker should exclude the
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options that have normal values in them,
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such as eupnea, pulse rate of 90, and
bb bb bb bb bb bb bb
capillary refill time (CRT) <3 seconds. bb bb bb bb bb
The nurse is developing a nursing care plan for a client diagnosed with congestive
bb bb bb bb bb bb bb bb bb bb bb bb bb
heart failure. A nursing diagnosis of "decreased cardiac output related to inability of
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the heart to pump effectively" is written. Which short-term goal would be best for the
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client? The client will: bb bb bb
1. Be able to ambulate in the hall by date of discharge.
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2. Have an audible S1 and S2 with no S3 heard by end of shift.
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3. Turn, cough, and deep breathe every two (2) hours.
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4. Have a pulse oximeter reading of 98% by day two (2) of care. - ANSWER: 2. Have an
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audible S1 and S2 with no S3 heard by end of shift.
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,1. Ambulating in the hall by day of discharge
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would be a more appropriate goal for an
bb bb bb bb bb bb bb
activity-intolerance nursing diagnosis. bb bb
2. Audible S1 and S2 sounds are normal for
bb bb bb bb bb bb bb bb
a heart with adequate output. An audible
bb bb bb bb bb bb
S3 sound might indicate left ventricular
bb bb bb bb bb
failure which could be life threatening.
bb bb bb bb bb
3. This is a nursing intervention, not a
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short-term goal, for this client. bb bb bb bb
4. A pulse oximeter reading would be a goal
bb bb bb bb bb bb bb bb
for impaired gas exchange, not for cardiac
bb bb bb bb bb bb
output.
TEST-TAKING HINT: When reading a nursing bb bb bb bb bb
diagnosis or problem, the test taker must bb bb bb bb bb bb
be sure that the answer selected addresses
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the problem. An answer option may be
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appropriate care for the disease process but bb bb bb bb bb bb
may not fit with the problem or etiology.
bb bb bb bb bb bb bb
Remember, when given an etiology in a bb bb bb bb bb bb
nursing diagnosis, the answer will be doing
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something about the problem (etiology). In bb bb bb bb bb
this question the test taker should look for an answer that addresses the ability of the
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
heart to pump blood. bb bb bb
The nurse is developing a discharge-teaching plan for the client diagnosed with
bb bb bb bb bb bb bb bb bb bb bb
, congestive heart failure. Which interventions should be included in the plan? Select all
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that apply. bb
1. Notify health-care provider of a weight gain of more than one (1) pound in a week.
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2. Teach client how to count the radial pulse when taking digoxin, a cardiac glycoside.
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3. Instruct client to remove the saltshaker from the dinner table.
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4. Encourage client to monitor urine output for change in color to become dark.
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5. Discuss the importance of taking the loop diuretic furosemide at bedtime. - ANSWER: 2.
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Teach client how to count the radial pulse when taking digoxin, a cardiac glycoside.
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1. The client should notify the HCP of weight
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gain of more than two (2) or three
bb bb bb bb bb bb bb
(3) pounds in one (1) day.
bb bb bb bb bb
2. The client should not take digoxin if the
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radial pulse is less than 60.
bb bb bb bb bb
3. The client should be on a low-sodium
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diet to prevent water retention.
bb bb bb bb
4. The color of the urine should not change to
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a dark color; if anything, it might become
bb bb bb bb bb bb bb
lighter and the amount will increase with
bb bb bb bb bb bb
diuretics.
5. Instruct the client to take the diuretic in the
bb bb bb bb bb bb bb bb bb
morning to prevent nocturia. bb bb bb
TEST-TAKING HINT: This is an alternativetype bb bb bb bb bb
question—in this case, "select all that bb bb bb bb bb
apply." If the test taker missed this statement,
bb bb bb bb bb bb bb
QUESTIONS WITH ACTUAL
SOLUTIONS.
The client is admitted to the telemetry unit diagnosed with acute exacerbation of
bb bb bb bb bb bb bb bb bb bb bb bb
congestive heart failure (CHF). Which signs/symptoms would the nurse expect to find
bb bb bb bb bb bb bb bb bb bb bb
when assessing this client?
bb bb bb
1. Apical pulse rate of 110 and 4+ pitting edema of feet.
bb bb bb bb bb bb bb bb bb bb bb
2. Thick white sputum and crackles that clear with cough.
bb bb bb bb bb bb bb bb bb
3. The client sleeping with no pillow and eupnea.
bb bb bb bb bb bb bb bb
4. Radial pulse rate of 90 and capillary refill time <3 seconds. - ANSWER: 1. Apical pulse rate
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
of 110 and 4+ pitting edema of feet.
bb bb bb bb bb bb bb bb
1. The client with CHF would exhibit
bb bb bb bb bb bb
tachycardia (apical pulse rate of 110), bb bb bb bb bb
dependent edema, fatigue, third heart bb bb bb bb
sounds, lung congestion, and change in bb bb bb bb bb
mental status. bb
2. The client with CHF usually has pink
bb bb bb bb bb bb bb
frothy sputum and crackles that do not clear
bb bb bb bb bb bb bb
with coughing. bb
3. The client with CHF would report sleeping
bb bb bb bb bb bb bb
on at least two pillows, if not sleeping in an
bb bb bb bb bb bb bb bb bb
,upright position, and labored breathing, not
bb bb bb bb bb
eupnea, which means normal breathing. bb bb bb bb
4. In a client diagnosed with heart failure, the
bb bb bb bb bb bb bb bb
apical pulse, not the radial pulse, is the best
bb bb bb bb bb bb bb bb
place to assess the cardiac status.
bb bb bb bb bb
TEST-TAKING HINT: In option "3," the word bb bb bb bb bb bb
"no" is an absolute term, and usually
bb bb bb bb bb bb
absolutes, such as "no," "never," "always," bb bb bb bb bb
and "only," are incorrect because there is
bb bb bb bb bb bb
no room for any other possible answer. If
bb bb bb bb bb bb bb
the test taker is looking for abnormal data,
bb bb bb bb bb bb bb
then the test taker should exclude the
bb bb bb bb bb bb
options that have normal values in them,
bb bb bb bb bb bb
such as eupnea, pulse rate of 90, and
bb bb bb bb bb bb bb
capillary refill time (CRT) <3 seconds. bb bb bb bb bb
The nurse is developing a nursing care plan for a client diagnosed with congestive
bb bb bb bb bb bb bb bb bb bb bb bb bb
heart failure. A nursing diagnosis of "decreased cardiac output related to inability of
bb bb bb bb bb bb bb bb bb bb bb bb
the heart to pump effectively" is written. Which short-term goal would be best for the
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
client? The client will: bb bb bb
1. Be able to ambulate in the hall by date of discharge.
bb bb bb bb bb bb bb bb bb bb bb
2. Have an audible S1 and S2 with no S3 heard by end of shift.
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
3. Turn, cough, and deep breathe every two (2) hours.
bb bb bb bb bb bb bb bb bb
4. Have a pulse oximeter reading of 98% by day two (2) of care. - ANSWER: 2. Have an
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
audible S1 and S2 with no S3 heard by end of shift.
bb bb bb bb bb bb bb bb bb bb bb bb
,1. Ambulating in the hall by day of discharge
bb bb bb bb bb bb bb bb
would be a more appropriate goal for an
bb bb bb bb bb bb bb
activity-intolerance nursing diagnosis. bb bb
2. Audible S1 and S2 sounds are normal for
bb bb bb bb bb bb bb bb
a heart with adequate output. An audible
bb bb bb bb bb bb
S3 sound might indicate left ventricular
bb bb bb bb bb
failure which could be life threatening.
bb bb bb bb bb
3. This is a nursing intervention, not a
bb bb bb bb bb bb bb
short-term goal, for this client. bb bb bb bb
4. A pulse oximeter reading would be a goal
bb bb bb bb bb bb bb bb
for impaired gas exchange, not for cardiac
bb bb bb bb bb bb
output.
TEST-TAKING HINT: When reading a nursing bb bb bb bb bb
diagnosis or problem, the test taker must bb bb bb bb bb bb
be sure that the answer selected addresses
bb bb bb bb bb bb
the problem. An answer option may be
bb bb bb bb bb bb
appropriate care for the disease process but bb bb bb bb bb bb
may not fit with the problem or etiology.
bb bb bb bb bb bb bb
Remember, when given an etiology in a bb bb bb bb bb bb
nursing diagnosis, the answer will be doing
bb bb bb bb bb bb
something about the problem (etiology). In bb bb bb bb bb
this question the test taker should look for an answer that addresses the ability of the
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
heart to pump blood. bb bb bb
The nurse is developing a discharge-teaching plan for the client diagnosed with
bb bb bb bb bb bb bb bb bb bb bb
, congestive heart failure. Which interventions should be included in the plan? Select all
bb bb bb bb bb bb bb bb bb bb bb bb
that apply. bb
1. Notify health-care provider of a weight gain of more than one (1) pound in a week.
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
2. Teach client how to count the radial pulse when taking digoxin, a cardiac glycoside.
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
3. Instruct client to remove the saltshaker from the dinner table.
bb bb bb bb bb bb bb bb bb bb
4. Encourage client to monitor urine output for change in color to become dark.
bb bb bb bb bb bb bb bb bb bb bb bb bb
5. Discuss the importance of taking the loop diuretic furosemide at bedtime. - ANSWER: 2.
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
Teach client how to count the radial pulse when taking digoxin, a cardiac glycoside.
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
1. The client should notify the HCP of weight
bb bb bb bb bb bb bb bb
gain of more than two (2) or three
bb bb bb bb bb bb bb
(3) pounds in one (1) day.
bb bb bb bb bb
2. The client should not take digoxin if the
bb bb bb bb bb bb bb bb
radial pulse is less than 60.
bb bb bb bb bb
3. The client should be on a low-sodium
bb bb bb bb bb bb bb
diet to prevent water retention.
bb bb bb bb
4. The color of the urine should not change to
bb bb bb bb bb bb bb bb bb
a dark color; if anything, it might become
bb bb bb bb bb bb bb
lighter and the amount will increase with
bb bb bb bb bb bb
diuretics.
5. Instruct the client to take the diuretic in the
bb bb bb bb bb bb bb bb bb
morning to prevent nocturia. bb bb bb
TEST-TAKING HINT: This is an alternativetype bb bb bb bb bb
question—in this case, "select all that bb bb bb bb bb
apply." If the test taker missed this statement,
bb bb bb bb bb bb bb
