NSG 54 Final Exam Prep (2025) – Complete
Verified Questions & 100% Correct Answers
What abnormal assessment findings might you expect to find in DHC (Decompensated Heart Failure)?
-Neuro: Hypoxia to the brain from decreased O2 can cause confusion/restlessness
-Cardio:
1:Tachycardia present, Jugular vein distention JVD
2:Irregular heartbeat (Arrhythmia)
3:Skin may be cool/clammy and pt may be cyanotic
4:Edema: peripheral pitting edema, low or decreased perfusion (Capillary refill >3 sec)
5:Chest pain
-Resp:
1:Rales/Crackles may be heard
2:Dyspnea/SOB/fatigue/wheeze develops with less exertion/rest
3:Non-productive cough may be present
-Urine output: may decrease because of decreased renal perfusion
-Weight gain: due to fluid retention
Review the therapeutic and side effects of Furosemide (Lasix)
Fast-acting loop diuretic *K wasting - monitor electrolytes
-Indication: Reduce edema due to heart failure
-Therapeutic: Is a diuretic, that helps your body get rid of sodium/water
-Side effects: Blurred vision, dizziness(increase risk for fall), dehydration (electrolyte
imbalance) hyperglycemia, dehydration, ototoxicity
-Assessment parameters: Hold if SBP is less than 90, look at potassium labs too
,What diet should I expect to be prescribed for Mr. Bishop due to his DHF?
-Fluid restriction, limited NA
-Cardiac diet: Promotes heart health
-Diet includes: fruits/vegetables, whole grains, lean poultry, salmon/tuna (high in
omega-3)
-Avoid: Limit processed foods, foods high in salt/sugar/unhealthy fats (saturated
fats)/red meat
Case Study: Patty is a 98-year-old retired teacher who has been admitted to the hospital after having a
CVA. Her neighbor checks on her, helps her around the house, and cooks her meals for her. When she
checked on her today she noticed Patty was confused and weak. She has been admitted for observation
and continued diagnostics. Patty will need an admission assessment, routine nursing care and
medications administered.
What are some appropriate nursing diagnosis statements for Patty?
Risk for falls
Impaired physical mobility
Self-Care Deficit
Risk for impaired swallowing
Fatigue Impaired Transfer ability
Impaired Walking Disability
-associated urinary incontinence
Frail Elderly Syndrome
Acute Confusion
, What are swallowing precautions?
-Determined by a speech therapist
-Can also be called aspiration risk (precautions)
-Appropriate texture and fluid thickness will be recommended
Some or all of the following can be advised:
Eat with HOB positioned at 90 degrees
● Make sure the patient is fully alert to eat
● Limit distractions (TV off) limit talking
● Small bites/small sips
● Alternate consistencies of food/liquids
○ Do not have both in the same mouth full ● Use of straw will be indicated
● Tuck chin to chest to swallow
● Double swallow to make sure the food is going down the esophagus
● Eat slowly and mindfully reminders
● Suction available
● Oral care before and after meals, pt stays up for 30 min after eating
thickened liquids & pureed diet consistencies
Thickened Liquids
1. Clear Liquids (Thins) Jello, broth, juice w/no pulp
2. Nectar thick (thickening agent added to thins directions on packaging)
2. Full Liquids (thins plus cream based +cream of wheat)
3. Honey (thickener is added to make a honey consistency according to directions)
3. Pureed Foods (blended consistency of food)
4. Pudding thick (thickener added until pudding thick)
Review restraints protocol including alternatives.
Verified Questions & 100% Correct Answers
What abnormal assessment findings might you expect to find in DHC (Decompensated Heart Failure)?
-Neuro: Hypoxia to the brain from decreased O2 can cause confusion/restlessness
-Cardio:
1:Tachycardia present, Jugular vein distention JVD
2:Irregular heartbeat (Arrhythmia)
3:Skin may be cool/clammy and pt may be cyanotic
4:Edema: peripheral pitting edema, low or decreased perfusion (Capillary refill >3 sec)
5:Chest pain
-Resp:
1:Rales/Crackles may be heard
2:Dyspnea/SOB/fatigue/wheeze develops with less exertion/rest
3:Non-productive cough may be present
-Urine output: may decrease because of decreased renal perfusion
-Weight gain: due to fluid retention
Review the therapeutic and side effects of Furosemide (Lasix)
Fast-acting loop diuretic *K wasting - monitor electrolytes
-Indication: Reduce edema due to heart failure
-Therapeutic: Is a diuretic, that helps your body get rid of sodium/water
-Side effects: Blurred vision, dizziness(increase risk for fall), dehydration (electrolyte
imbalance) hyperglycemia, dehydration, ototoxicity
-Assessment parameters: Hold if SBP is less than 90, look at potassium labs too
,What diet should I expect to be prescribed for Mr. Bishop due to his DHF?
-Fluid restriction, limited NA
-Cardiac diet: Promotes heart health
-Diet includes: fruits/vegetables, whole grains, lean poultry, salmon/tuna (high in
omega-3)
-Avoid: Limit processed foods, foods high in salt/sugar/unhealthy fats (saturated
fats)/red meat
Case Study: Patty is a 98-year-old retired teacher who has been admitted to the hospital after having a
CVA. Her neighbor checks on her, helps her around the house, and cooks her meals for her. When she
checked on her today she noticed Patty was confused and weak. She has been admitted for observation
and continued diagnostics. Patty will need an admission assessment, routine nursing care and
medications administered.
What are some appropriate nursing diagnosis statements for Patty?
Risk for falls
Impaired physical mobility
Self-Care Deficit
Risk for impaired swallowing
Fatigue Impaired Transfer ability
Impaired Walking Disability
-associated urinary incontinence
Frail Elderly Syndrome
Acute Confusion
, What are swallowing precautions?
-Determined by a speech therapist
-Can also be called aspiration risk (precautions)
-Appropriate texture and fluid thickness will be recommended
Some or all of the following can be advised:
Eat with HOB positioned at 90 degrees
● Make sure the patient is fully alert to eat
● Limit distractions (TV off) limit talking
● Small bites/small sips
● Alternate consistencies of food/liquids
○ Do not have both in the same mouth full ● Use of straw will be indicated
● Tuck chin to chest to swallow
● Double swallow to make sure the food is going down the esophagus
● Eat slowly and mindfully reminders
● Suction available
● Oral care before and after meals, pt stays up for 30 min after eating
thickened liquids & pureed diet consistencies
Thickened Liquids
1. Clear Liquids (Thins) Jello, broth, juice w/no pulp
2. Nectar thick (thickening agent added to thins directions on packaging)
2. Full Liquids (thins plus cream based +cream of wheat)
3. Honey (thickener is added to make a honey consistency according to directions)
3. Pureed Foods (blended consistency of food)
4. Pudding thick (thickener added until pudding thick)
Review restraints protocol including alternatives.
