A&E II Exam 2 / Q-Bank / Complete Accurate Quizzes with Verified Answers / 2025.Quiz____?The home care nurse visits a patient with chronic heart failure who is taking digoxin and furosemide. The patient complains of nausea and vomiting. Which action is most appropriate for the nurse to take?
A:Perform a dipstick urine test for protein.
B:Notify the health care provider immediately.
C: Have the patient eat foods high in potassium.
D:Ask the patient to record a weight every morning. -
Answer✓✓
B: Notify the health care provider immediately.
Quiz____?A patient with left-sided heart failure is prescribed oxygen at 4 L/min per nasal cannula, furosemide, spironolactone, and enalapril. Which assessment should the nurse complete to best evaluate the patient's response to these drugs?
A: Observe skin turgor
B: Auscultate lung sounds
C: Measure blood pressure
D: Review intake and output -
Answer✓✓
B: Auscultate lung sounds
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Left = Lungs Quiz____?While assessing a 68-year-old with ascites, the nurse also notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. The nurse knows this finding indicates a.decreased fluid volume.b.jugular vein atherosclerosis.c.increased right atrial pressure.d.incompetent jugular vein valves. - Answer✓✓ c.increased right atrial pressure.The jugular veins empty into the superior vena cava and then into the right atrium, so JVD with the patient sitting at a 45-degree angle reflects increased right atrial pressure.JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid volume. JVD is not caused by incompetent jugular vein valves or atherosclerosis.Quiz____?The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective?a.Weight loss of 2 pounds in 24 hours b.Hourly urine output greater than 60 mL c.Reduction in patient complaints of chest pain Page 2 of 180 2 / 4
d.Reduced dyspnea with the head of bed at 30 degrees - Answer✓✓ d.Reduced dyspnea with the head of bed at 30 degrees Because the patient's major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in dyspnea with the head of the bed at 30 degrees. The other assessment data also may indicate that diuresis or improvement in cardiac output has occurred, but are not as specific to evaluating this patient's response.Quiz____?Which topic will the nurse plan to include in discharge teaching for a patient with systolic heart failure and an ejection fraction of 33%?a.Need to begin an aerobic exercise program several times weekly b.Use of salt substitutes to replace table salt when cooking and at the table c.Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors d.Importance of making an annual appointment with the primary care provider - Answer✓✓ c.Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors The core measures for the treatment of heart failure established by The Joint Commission indicate that patients with an ejection fraction (EF) <40% receive an ACE inhibitor to decrease the progression of heart failure.Aerobic exercise may not be appropriate for a patient with this level of heart failure, salt substitutes are not usually recommended because of the Page 3 of 180 3 / 4
risk of hyperkalemia, and the patient will need to see the primary care provider more frequently than annually.Quiz____?IV sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to titrate the nitroprusside rate if the patient develops a.ventricular ectopy.b.a dry, hacking cough.c.a systolic BP <90 mm Hg.d.a heart rate <50 beats/minute. - Answer✓✓ c.a systolic BP <90 mm Hg.Sodium nitroprusside is a potent vasodilator, and the major adverse effect is severe hypotension. Coughing and bradycardia are not adverse effects of this medication. Nitroprusside does not cause increased ventricular ectopy.Quiz____?A patient who has chronic heart failure tells the nurse, "I was fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" The nurse will document this assessment finding as a.orthopnea.b.pulsus alternans.c.paroxysmal nocturnal dyspnea.d.acute bilateral pleural effusion. - Answer✓✓ Page 4 of 180
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