Heart Failure NCLEX Questions (1-5)

Welcome to Heart Failure NCLEX Questions. Before you begin answering the questions, you may first want to take a peek about the material that will surely help you the pass the NCLEX examination :

Complete NCLEX Study Materials

Enjoy answering and I hope that Nurse Certifications can somehow help you in your future examination.

Good Luck

 

1. As part of cardiac assessment, the nurse palpates the apical pulse. To perform this assessment, the nurse places the fingertips at which of the following locations?

a) at the left midclavicular line at the fifth intercostal space
b) at the left midclavicular line at the third intercostal space
c) to the right of the midclavicular line at the fifth intercostal space
d) to the right of the midclavicular line at the third intercostal space

 

2. A nurse is assessing the client with left-sided heart failure. The client states that he needs to use three pillows under the head and chest at night to be able to breathe comfortably while sleeping. The nurse documents that the client is experiencing:

a) orthopnea
b) dyspnea at rest
c) dyspnea on exertion
d) paroxysmal nocturnal dyspnea

 

3. The nurse suspects that a client who had a myocardial infarction is developing cardiogenic shock. The nurse assesses for which peripheral vascular manifestation of this complication?

a) flushed, dry skin with bounding pedal pulses
b) warm, moist skin with irregular pedal pulses
c) cool, clammy skin with weak or thready pedal pulses
d) cool, dry skin with alternating weak and strong peal pulses

 

4. The nurse is caring for a client who returns from cardiac surgery with chest tubes in place. The nurse assesses the drainage on an hourly basis and determines that the client is stable as long as drainage does not exceed how many milliliters over the 24 hours?

a) 100
b) 200
c) 500
d) 1000

 

5. The home health nurse is performing an initial assessment on a client who has arrived home after insertion of a permanent pacemaker. Evaluation of the client’s understanding of self-care is evident if the client reports which of the following?

a) I will never be able to operate a microwave oven again
b) I should expect occasional feelings of dizziness and fatigue
c) I will take my pulse in the wrist or neck daily and record it in a log
d) moving my arms and shoulders vigorously helps to check pacemaker functioning

 

 

Heart Failure NCLEX Questions
Answers and Rationale

 

1) A
– The point of maximal impulse (PMI), where the apical pulse is palpated, is normally located in the fourth or fifth intercostal space, at the left midclavicular line.

 

2) A
– Dyspnea is a subjective complaint that can range from an awareness of breathing to physical distress and does not necessarily correlate with the degree of heart failure. Dyspnea can be exertional or at rest. Orthopnea is a more severe form of dyspnea, requiring the client to assume a “three-point” position while upright and use pillows to support the head and thorax at night. Paroxysmal nocturnal dyspnea is a severe form of dyspnea occurring suddenly at night because of rapid fluid reentry into the vasculature from the interstitium during sleep.

 

3) C
– Classic signs of cardiogenic shock include increased pulse (weak and thready), decreased blood pressure, decreasing urinary output, signs of cerebral ischemia (confusion, agitation), and cool, clammy skin.

 

4) C
– Chest tube drainage should not exceed 100 mL per hour during the first 2 hours postoperatively, and approximately 500 mL of drainage is expected in the first 24 hours after cardiac surgery. The nurse measures and records the drainage on an hourly basis. The drainage is initially dark red and becomes more serous over time.

 

5) C
– Clients with permanent pacemakers must be able to take their pulse in the wrist and/or neck accurately in order to note any variation in the pulse rate or rhythm that may need to be reported to the physician. Clients can safely operate most appliances and tools, such as microwave ovens, video recorders, AM-FM radios, electric blankets, lawn mowers, and leaf blowers, as long as the devices are grounded and in good repair. If the client experiences any feelings of dizziness, fatigue, or an irregular heartbeat, the physician is notified. The arms and shoulders should not be moved vigorously for 6 weeks after insertion.

 

After you reviewed your answers through its rationale, you can now proceed to the next set of questions:

Heart Failure NCLEX Questions (6-10)

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