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Congestive Heart Failure Practice Questions (Test #5, Fall 2024)
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Congestive Heart Failure Practice Questions (Test #5, Fall 2024)
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Congestive Heart Failure PracticeQuestions (Test #5, Fall 2024)
The client is admitted to the telemetry unit diagnosed with acute
exacerbation of congestive heart failure (CHF). Which signs/symptoms would
the nurse expect to find when assessing this client?
1. Apical pulse rate of 110 and 4+ pitting edema of feet.
2. Thick white sputum and crackles that clear with cough.
3. The client sleeping with no pillow and eupnea.
4. Radial pulse rate of 90 and CRT less than three (3) seconds. - -1
1. The client with CHF would exhibit tachycardia (apical pulse rate of 110),
dependent edema, fatigue, third heart sounds, lung congestion, and change
in mental status.
2. The client with CHF usually has pink frothy sputum and crackles that do
not clear with coughing.
3. The client with CHF would report sleeping on at least two pillows, if not
sleeping in an upright position, and labored breathing, not eupnea, which
means normal breathing.
4. In a client diagnosed with heart failure, the apical pulse, not the radial
pulse, is the best place to assess the cardiac status.
TEST-TAKING HINT: In option "3," the word "no" is an absolute term and,
usually, absolutes, such as "no," "never," "always," and "only," are incorrect
because there is no room for any other possible answer. If the test taker is
looking for abnormal data, then the test taker should exclude the options
that have normal values in them, such as eupnea, pulse rate of 90, and
capillary refill time (CRT) less than three (3) seconds.
- The nurse is developing a nursing care plan for a client diagnosed with
congestive heart failure. A nursing diagnosis of "decreased cardiac output
related to inability of the heart to pump effectively" is written. Which short-
term goal would be best for the client?
1. The client will be able to ambulate in the hall by date of discharge.
2. The client will have an audible S1 and S2 with no S3 heard by end of shift.
3. The client will turn, cough, and deep breathe every two (2) hours. 4. The
client will have a SaO2 reading of 98% by day two (2) of care - -2
1. Ambulating in the hall by day of discharge would be a more appropriate
goal for an activity-intolerance nursing diagnosis.
,2. Audible S1 and S2 sounds are normal for a heart with adequate output. An
audible S3 sound might indicate left ventricular failure, which could be life
threatening.
3. This is a nursing intervention, not a short-term goal, for this client.
4. A pulse oximeter reading would be a goal for impaired gas exchange, not
for cardiac output.
TEST-TAKING HINT: When reading a nursing diagnosis or problem, the test
taker must be sure that the answer selected addresses the problem. An
answer option may be appropriate care for the disease process but may not
fit with the problem or etiology. Remember, when given an etiology in a
nursing diagnosis, the answer will be doing something about the problem
(etiology). In this question the test taker should look for an answer that
addresses the ability of the heart to pump blood.
- The nurse is developing a discharge-teaching plan for the client diagnosed
with congestive heart failure. Which interventions should be included in the
plan? Select all that apply.
1. Notify the health-care provider of a weight gain of more than one (1)
pound in a week.
2. Teach the client how to count the radial pulse when taking digoxin, a
cardiac glycoside.
3. Instruct the client to remove the saltshaker from the dinner table.
4. Encourage the client to monitor urine output for change in color to
become dark.
5. Discuss the importance of taking the loop diuretic furosemide at bedtime.
- -2,3
1. The client should notify the HCP of weight gain of more than two (2) or
three (3) pounds in one (1) day.
2. The client should not take digoxin if the radial pulse is less than 60.
3. The client should be on a low-sodium diet to prevent water retention.
4. The color of the urine should not change to a dark color; if anything, it
might become lighter and the amount will increase with diuretics.
5. Instruct the client to take the diuretic in the morning to prevent nocturia.
TEST-TAKING HINT: This is an alternative-type question—in this case, "Select
all that apply." If the test taker missed this statement, it is possible to jump
at the first correct answer. This is one reason that it is imperative to read all
options before deciding on the correct one(s). This could be a clue to reread
, the question for clarity. Another hint that this is an alternative question is the
number of options. The other questions have four potential answers; this one
has five. Numbers in an answer option are always important. Is one (1)
pound enough to indicate a problem that should be brought to the attention
of the health-care provider?
- The nurse enters the room of the client diagnosed with congestive heart
failure. The client is lying in bed gasping for breath, is cool and clammy, and
has buccal cyanosis. Which intervention would the nurse implement first?
1. Sponge the client's forehead.
2. Obtain a pulse oximetry reading.
3. Take the client's vital signs.
4. Assist the client to a sitting position - -4
1. Sponging dry the client's forehead would be appropriate, but it is not the
first intervention.
2. Obtaining a pulse oximeter reading would be appropriate, but it is not the
first intervention.
3. Taking the vital signs would be appropriate, but it is not the first
intervention.
4. The nurse must first put the client in a sitting position to decrease the
workload of the heart by decreasing venous return and maximizing lung
expansion. Then, the nurse could take vital signs and check the pulse
oximeter and then sponge the client's forehead.
TEST-TAKING HINT: In a question that asks the nurse to set priorities, all the
answer options can be appropriate actions by the nurse for a given situation.
The test taker should apply some guidelines or principles, such as Maslow's
hierarchy, to determine what will give the client the most immediate
assistance.
- The nurse is assessing the client diagnosed with congestive heart failure.
Which signs/symptoms would indicate that the medical treatment has been
effective?
1. The client's peripheral pitting edema has gone from 3+ to 4+.
2. The client is able to take the radial pulse accurately.
3. The client is able to perform ADLs without dyspnea.
4. The client has minimal jugular vein distention. - -3
1. Pitting edema changing from 3+ to 4+ indicates a worsening of the CHF.
2. The client's ability to take the radial pulse would evaluate teaching, not
medical treatment.
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