Nclex practice questions: HF, MI and

Nclex practice questions: HF, MI and

angina

• The client is admitted to the telemetry unit diag-

nosed with left-sided heart failure. Which clinical manifestations would the nurse expect to find when assessing this client?

• Apical pulse rate of 110 and crackles on

auscultation.

• Jugular vein distention and 4+ pitting edema

of feet.

• The client sleeping with no pillow and eupnea.
• Radial pulse rate of 90 and CRT less than
• seconds. - Answer- 1. The client diagnosed with left-sided

heart failure would exhibit tachycardia (apical pulse rate of 110), shortness of breath, crackles on auscultation, fatigue, third heart sounds, and change in mental status.

• The nurse is developing a nursing care plan for

a client diagnosed with left-sided heart failure.A nursing diagnosis of "decreased cardiac output related to the inability of the heart to pump effec- tively" is written. Which short-term goal would be best for the client?

• The client will be able to ambulate in the hall

by date of discharge.

• The client will have an audible S1 and S2 with

no S3, heard by the end of shift.

• The client will turn, cough, and deep breathe

every 2 hours.

• The client will have a Sao, reading of 98% by

day 2 of care. - Answer- 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.

• The nurse is developing a discharge-teaching plan

for the client diagnosed with heart failure. Which interventions should be included in the plan? This study source was downloaded by 100000897174347 from CourseHero.com on 03-10-2025 22:57:23 GMT -05:00 https://www.coursehero.com/file/245701753/Nclex-practice-questions-HF-MI-and-anginadocx/

Select all that apply.

• Notify the health-care provider (HCP) of a

weight gain of more than 1 pound in a week.

• Teach the client how to count the radial pulse

when taking digoxin.

• Instruct the client to remove the saltshaker

from the dinner table.

• Encourage the client to monitor urine output

for change to a dark color.

• Discuss the importance of taking furosemide at

bedtime. - Answer- 2.The client should not take digoxin, a car- diac glycoside, if the radial pulse is less than 60.

• The client should be on a low-sodium

diet to prevent water retention.

• The nurse enters the room of the client diagnosed

with heart failure. The client is lying in bed gasp- ing for breath, is cool and clammy, and has buc- cal cyanosis. Which intervention would the nurse implement first?

• Sponge the client's forehead.
• Obtain a pulse oximetry reading.
• Take the client's vital signs.
• Assist the client to a sitting position. - Answer- 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.

• The nurse is assessing the client diagnosed with

heart failure. Which clinical manifestations would indicate that medical treatment has been effective?

• The client's peripheral pitting edema has gone

from 3+ to 4+.

• The client is able to take the radial pulse

accurately.

• The client is able to perform activities of daily

living (ADLs) without dyspnea.

• The client has minimal jugular vein distention. - Answer- 3. Being able to perform

ADLs without This study source was downloaded by 100000897174347 from CourseHero.com on 03-10-2025 22:57:23 GMT -05:00 https://www.coursehero.com/file/245701753/Nclex-practice-questions-HF-MI-and-anginadocx/

shortness of breath (dyspnea) would indicate the client's condition is improv- ing. The client's heart is a more effective pump and can oxygenate the body better without increasing fluid in the lungs.

• The nurse is assessing the client diagnosed with

heart failure. Which laboratory data would indi- cate that the client is in heart failure?

• An elevated B-type natriuretic peptide (BNP).
• An elevated creatine kinase (CK-MB).
• A positive D-dimer.
• A positive ventilation-perfusion (VQ) scan - Answer- 1. BNP is a specific diagnostic

test to diag- nose heart failure. Levels higher than normal indicate heart failure and the need for additional assessment such as echocardiography (VanLeeuwen & Bladh,

2017).

• The HCP has ordered an angiotensin-converting

enzyme (ACE) inhibitor for the client diagnosed with heart failure. Which discharge instructions should the nurse include? Select all that apply.

• Instruct the client to take a cough suppressant

if a cough develops.

• Teach the client how to prevent orthostatic

hypotension.

• Encourage the client to eat bananas to increase

potassium levels.

• Explain the importance of taking the medica-

tion with food.

• Tell the client to avoid the use of NSAIDs. - Answer- 2. Orthostatic hypotension 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.

• ACE inhibitors taken with NSAIDs can

cause an adverse effect in the kidneys and decrease the antihypertensive benefits of the ACE inhibitor.

• The nurse on the telemetry unit has just received This study source was downloaded by 100000897174347 from CourseHero.com on 03-10-2025 22:57:23 GMT -05:00

https://www.coursehero.com/file/245701753/Nclex-practice-questions-HF-MI-and-anginadocx/

the morning shift report. Which client should the nurse assess first?

• The client diagnosed with myocardial infarction (MI) with an audible S3 heart sound.
• The client diagnosed with right-sided heart

failure with 4+ sacral pitting edema.

• The client diagnosed with pneumonia with a

pulse oximeter reading of 94%.

• The client diagnosed with chronic renal failure with an elevated creatinine level. -

Answer- 1. An S3 heart sound indicates left-sided heart failure, and the nurse must assess this client first because it is an emergency situation.

• The nurse and an unlicensed assistive personnel

(UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the RN to delegate to the UAP?

• Assist the client to go down to the smoking

area for a cigarette.

• Transport the client to the intensive care unit

ICU) via a stretcher.

• Provide the client going home discharge-

teaching instructions.

• Help position the client having a portable

×-ray done. - Answer- 4. The UAP can assist the x-ray technician in positioning the client for the portable ×-ray. This does not require judgment.

• The charge nurse is making shift assignments for

the medical floor. Which client should be assigned to the most experienced registered nurse?

• The client diagnosed with chronic heart fail.

ure being discharged in the morning.

• The client having frequent incontinent liquid

bowel movements and vomiting.

• The client with an apical pulse rate of 116, a

respiratory rate of 26, and a blood pressure of

94/62.

• The client reporting chest pain on inspiration

and a nonproductive cough. - Answer- 3. This client is exhibiting clinical man- ifestations of shock, which makes this client the most unstable. An experi- enced nurse should care for this client.

• The client diagnosed with chronic heart failure

is reporting leg cramps at night. Which nursing interventions should be implemented? This study source was downloaded by 100000897174347 from CourseHero.com on 03-10-2025 22:57:23 GMT -05:00 https://www.coursehero.com/file/245701753/Nclex-practice-questions-HF-MI-and-anginadocx/