CHF NCLEX style Questions

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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 9- and capillary refill time <3 seconds.
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1. The client with CHF would exhibit tachycardia, dependent edema, fatigue, third heart sounds, lung congestion, and change in mental status
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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. Be able to ambulate in the hall by date of discharge 2. Have an audible S1 and S2 with no S3 heard by end of shift 3. Turn, cough, and deep breathe every two hours 4. Have a pulse oximeter reading of 98% by day two of care
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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.
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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 health-care provider of a weight gain of more than one pound a week. 2. Teach client how to count the radial pulse when taking digoxin, a cardiac glycoside. 3. Instruct client to remove the saltshaker from the dinner table. 4. Encourage client to monitor urine output for change in color to become dark 5. Discuss the importance of taking the loop diuretic furosdemide at bedtime
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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.
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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 into a sitting position
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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 would take vital signs and check the pulse oximeter and then sponge the client’s forehead.
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The nurse is assessing the client diagnosed with congestive heart failure. Which signs/symptoms would indicate that medical treatment has been effective? 1. The client’s peripheral pitting edema has gone from a +3 to a +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
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3. Being able to perform activities of daily living without shortness of breath would indicate the client’s condition is improving. The client’s heart is a more effective pump and can oxygenate the body better without increasing fluid in the lungs.
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The nurse is assessing the client diagnosed with congestive heart failure. Which laboratory data would indicate that the client is in severe congestive heart failure? 1. An elevated B-type natriuretic peptide (BNP) 2. An elevated creatine kinase (CK-MB) 3. A positive D-Dimer 4. A positive ventilation/perfusion (V/Q) scan
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1. BNP is a specific diagnostic test. Levels higher than normal indicate congestive heart failure, with the higher the number the more severe the CHF
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The health-care provider has ordered an angiotensin-converting enzyme (ACE) inhibitor for the client diagnosed with congestive heart failure. Which discharge instructions should the nurse include? 1. Instruct the client to take a cough suppressant if a cough develops 2. Teach the client how to prevent orthostatic hypotension 3. Encourage the client to eat bananas to increase potassium level 4. Explain the importance of taking the medication with food
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2. Orthostatic hypotenstion may occur with ACE inhibitors as a result of vasodilation. Therefore, the nurse should instruct the client to rise slowly and sit on the side of the bed until equilibrium is restored.
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The nurse on the telemetry unit has just received the a.m. shift report. Which client should the nurse assess first? 1. The client diagnosed with myocardial infarction who has an audible S3 heart sound 2. The client diagnosed with congestive heart failure who has 4+ sacral pitting edema 3. The client diagnosed with pneumonia who has a pulse oximeter reading of 94% 4. The client with chronic renal failure who has an elevated creatinine level
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1. A S3 heart sound indicated left ventricular failure, and the nurse must assess this client first because it is an emergency situation.
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The nurse and an unlicensed assistive personnel are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP? 1. Assist the client to go down to the smoking area for a cigarette. 2. Transport the client to the intensive care unit via stretcher 3. Provide the client going home discharge teaching instructions 4. Help position the client who is having a portable x-ray done
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4. The UAP can assist the x-ray technician in positioning the client for the portable x-ray. This does not require judgement
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The charge nurse is making shift assignments for the medical floor. Which client should be assigned to the most experienced registered nurse? 1. The client diagnosed with congestive heart failure who is being discharged in the morning 2. The client who is having frequent incontinent liquid bowel movements and vomiting 3. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62. 4. The client who is complaining of chest pain with inspiration and a nonproductive cough
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3. This client is exhibition signs/symptoms of shock, which makes this client the most unstable. An experienced nurse should care for this client.
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The client diagnosed with congestive heart failure is complaining of leg cramps at night. Which nursing interventions should be implemented? 1. Check the client for peripheral edema and make sure the client takes a diuretic early in the day 2. Monitor the client’s potassium level and assess the client’s intake of bananas and orange juice 3. Determine if the client has gained weight and instruct the client to keep the legs elevated 4. Instruct the client to ambulate frequently and perform calf-muscle stretching exercises daily.
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2. The most probable cause of the leg cramping is potassium excretion as a result of diuretic medication. Bananas and orange juice are foods that are high in potassium
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The nurse has written an outcome goal “demonstrates tolerance for increased activity” for a client diagnosed with congestive heart failure. Which intervention should the nurse implement to assist the client to achieve this outcome? 1. Measure intake and output 2. Provide two gram sodium diet 3. Weigh client daily 4. Plan for frequent rest periods
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4. Scheduling activities and rest periods allows the client to participate in his or her own care and addresses the desired outcome

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