Unit 2

Question 1

65 yr old patient with a history of heart failure comes to the clinic with complaints of “being awakened from sleep with shortness of breath.” Which action by the nurse is most appropriate?
Obtain a detailed history of the patient’s allergies and history of asthma.
Tell the patient to sleep on his or her right side to facilitate ease of respirations.
Assess for other signs and symptoms of paroxysmal nocturnal dyspnea.
Assure the patient that this is normal and will probably resolve within the next week.
of heart failure

Answer 1

Assess for other signs and symptoms of paroxysmal nocturnal dyspnea.

Question 2

During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from:
Shallow breathing.
Normal lung tissue.
Decreased adipose tissue.
Increased density of lung tissue.

Answer 2

Increased density of lung tissue.

Question 3

When auscultating the lungs of an adult patient, the nurse notes that over the posterior lower lobes low-pitched, soft breath sounds are heard, with inspiration being longer than expiration. The nurse interprets that these are:
Sounds normally auscultated over the trachea.
Bronchial breath sounds and are normal in that location.
Vesicular breath sounds and are normal in that location.
Bronchovesicular breath sounds and are normal in that location.

Answer 3

Vesicular breath sounds and are normal in that location.

Question 4

A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this situation?
Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, ankle edema
Rasping cough, thick mucoid sputum, wheezing, bronchitis
Productive cough, dyspnea, weight loss, anorexia, tuberculosis
Fever, dry nonproductive cough, diminished breath sounds

Answer 4

Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, ankle edema

Question 5

When listening to heart sounds, the nurse knows that the valve closures that can be heard best at the base of the heart are:
Mitral and tricuspid.
Tricuspid and aortic.
Aortic and pulmonic.
Mitral and pulmonic.

Answer 5

Aortic and pulmonic.

Question 6

The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates:
Decreased fluid volume.
Increased cardiac output.
Narrowing of jugular veins.

Answer 6

Increased cardiac output.

Elevated pressure related to heart failure

Question 7

During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This finding would indicate:
A valvular disorder.
Blood flow turbulence.
Fluid volume overload.
Ventricular hypertrophy.

Answer 7

Blood flow turbulence.

Question 8

In assessing a patient’s major risk factors for heart disease, which would the nurse want to include when taking a history?
Family history, hypertension, stress, age
Personality type, high cholesterol, diabetes, smoking
Smoking, hypertension, obesity, diabetes, high cholesterol
Alcohol consumption, obesity, diabetes, stress, high cholesterol

Answer 8

Smoking, hypertension, obesity, diabetes, high cholesterol