Basic Pharmacology for Nurses 17th Ed by Clayton – Willihnganz – Test Bank

Complete Test Bank With Answers

 

 

 

Sample Questions Posted Below

 

 

 

 

Chapter 05: Patient Education to Promote Health

Clayton/Willihnganz: Basic Pharmacology for Nurses, 17th Edition

 

MULTIPLE CHOICE

 

1. The nurse is educating a 13-year-old boy newly diagnosed with diabetes and his parents about diet and glucose monitoring. Which domain of learning is represented when the patient expresses concern about feeling different from his peers?

a.	Cognitive
b.	Psychomotor
c.	Affective
d.	Learning style

 

 

ANS:  C

The affective domain is characterized by conduct that expresses feelings, needs, beliefs, values, and opinions. The cognitive domain relates to basic factual knowledge. The psychomotor domain relates to kinesthetic knowledge, implemented in performance and skills requiring coordination. Learning style is not one of the three domains of learning.

 

DIF:    Cognitive Level: Comprehension     REF:   Page 49          OBJ:   1

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Safe, Effective Care Environment

NOT:  CONCEPT(S): Patient Education; Health Promotion

 

2. The nurse has taught a patient’s spouse to administer an injectable medication. After the spouse completed a return demonstration of the injection in the hospital, the nurse does not feel confident that this can be carried out independently at home and requests referral for a home health nurse. The nurse is using which phase of the nursing process?

a.	Assessment
b.	Implementation
c.	Planning
d.	Evaluation

 

 

ANS:  D

The nurse has evaluated the injection technique of the patient’s spouse and determines additional instruction is needed. The nurse is not assessing the situation because she is not at the beginning of the process. The nurse is past implementation in the timeline of the process. The nurse has already planned and implemented interventions.

 

DIF:    Cognitive Level: Application           REF:   Page 51          OBJ:   5 | 6

TOP:   Nursing Process Step: Evaluation

MSC:  NCLEX Client Needs Category: Safe, Effective Care Environment

NOT:  CONCEPT(S): Clinical Judgment; Safety; Patient Education; Health Promotion; Care Coordination

 

3. In preparing for health teaching with a patient who has an auditory learning style, which would be most appropriate?

a.	Pamphlets from a pharmaceutical company
b.	Models of equipment used in a procedure
c.	Verbal description of the steps of a procedure
d.	A workbook with space to record actions and results

 

 

ANS:  C

Hearing the nurse present the information optimizes the patient’s perception of the data. Pamphlets from a pharmaceutical company or a workbook would be suitable for a patient who has a visual learning style. Models of equipment would be suitable for a patient with a psychomotor learning style.

 

DIF:    Cognitive Level: Analysis                REF:   Page 50          OBJ:   1 | 2 | 6

TOP:   Nursing Process Step: Evaluation

MSC:  NCLEX Client Needs Category: Safe, Effective Care Environment

NOT:  CONCEPT(S): Clinical Judgment; Patient Education; Communication

 

4. Which is the most intangible portion of the learning process?

a.	Cognitive
b.	Affective
c.	Psychomotor
d.	Eminent

 

 

ANS:  B

The affective domain concerns feelings, needs, beliefs, values, and opinions. The cognitive domain is the level at which basic knowledge is learned and stored; it is the thinking portion of the learning process. The psychomotor domain involves learning new procedures or skills; it is often referred to as the “doing domain.” Eminent domain in common law legal systems is the lawful power of the state to expropriate private property without the owner’s consent, either for its own use or on behalf of a third party.

 

DIF:    Cognitive Level: Knowledge            REF:   Page 49          OBJ:   1

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Patient Education

 

5. Which would positively affect readiness to learn?

a.	Fear and denial
b.	Willingness to attain an optimal level of health
c.	Poor cognitive and motor development
d.	Lack of trust and confidence in the staff

 

 

ANS:  B

Readiness or the ability to engage in learning depends on motive, relevant preparatory learning, and physiologic maturation. In fear and denial, the patient is neither prepared nor willing to accept the limitations imposed by the disease process and learn to manage lifestyle changes. Poor cognitive and motor development handicap the patient’s willingness and ability to learn. Trust is essential in the process of patient education. The patient must have confidence in the staff in order to be receptive to teaching efforts.

 

DIF:    Cognitive Level: Comprehension     REF:   Page 51          OBJ:   2

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Patient Education

 

6. Which represents the psychomotor domain of learning?

a.	The patient draws up insulin in a syringe.
b.	The patient expresses a belief about medication use.
c.	The patient is able to verbalize foods that should be avoided.
d.	The patient relates past experience with smoking cessation.

 

 

ANS:  A

The psychomotor domain involves the learning of a new procedure and is usually done by demonstration of the task. The patient expressing beliefs is an example of the affective domain. The patient verbalizing foods to be avoided is an example of the cognitive domain. The patient relating past experiences is an example of the affective domain.

 

DIF:    Cognitive Level: Comprehension     REF:   Page 50          OBJ:   1

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Patient Education

 

7. Which is an example of ethnocentrism?

a.	A 5-year-old Native American child colors in a book about diabetes.
b.	A 14-year-old African American attends a support group to learn about disease management.
c.	A 36-year-old Asian prefers to take herbs instead of an oral medication.
d.	A 72-year-old Hispanic asks questions about potential adverse effects to a newly prescribed medication.

 

 

ANS:  C

Ethnocentrism is the assumption that one’s culture provides the right way, and taking herbs instead of the medication exemplifies this belief. A 5-year-old Native American child coloring in a book about diabetes is an example of an age-appropriate learning process. A 14-year-old African American attending a support group to learn about disease management is an example of developmental impact on learning. A 72-year-old Hispanic person asking questions about potential adverse effects to a newly prescribed medication is demonstrating learning readiness.

 

DIF:    Cognitive Level: Comprehension     REF:   Page 54          OBJ:   2

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Patient Education

 

8. What is the most important nursing consideration when teaching an older adult patient about a newly prescribed medication?

a.	Provide detailed information.
b.	Lengthen the time of each teaching session.
c.	Present information slowly.
d.	Limit discussion on the necessity of learning the information.

 

 

ANS:  C

When teaching older adults, it is important to slow the pace of the presentation. Older adults process information more slowly because of limited short-term memory. Detailed information may be too overwhelming. The length of sessions should be limited for the older adult patient. Adults need to understand why they must learn something before they undertake the effort to learn.

 

DIF:    Cognitive Level: Comprehension     REF:   Page 53          OBJ:   6

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Patient Education; Communication

 

9. The nurse caring for a Spanish-speaking patient uses the assistance of an interpreter to help with preoperative teaching. While implementing the education, the nurse should

a.	look directly at the patient.
b.	never use pantomime gestures.
c.	ask lengthy questions to provide clarity.
d.	ask a family member to assist with interpretation.

 

 

ANS:  A

When using an interpreter, the nurse should look directly at the patient, not at the interpreter, while conversing. Sometimes supplementing questions with pictures and pantomime gestures may be helpful. The nurse should keep questions brief, asking them one at a time to give the interpreter an opportunity to rephrase the question and obtain a response. Whenever a third person enters into the communication cycle, lack of clarity and misinterpretation can occur.

 

DIF:    Cognitive Level: Application           REF:   Page 54          OBJ:   2 | 4 | 6

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Psychological Integrity

NOT:  CONCEPT(S): Health Promotion; Patient Education; Communication

 

10. A teaching plan has been developed by the nurse to educate the mother of a preterm infant on prescribed medications. Before initiating this teaching plan, the nurse should

a.	recognize the individual’s health beliefs.
b.	provide a formal learning setting.
c.	ensure that information is generalized.
d.	be sure that all care to the patient has been delivered.

 

 

ANS:  A

Before initiating a teaching plan, the nurse must recognize the individual’s health beliefs. Teaching does not require a formal setting. Because health teaching requires the integration of the patient’s beliefs, attitudes, values, opinions, and needs, an individualized teaching plan must be developed or a standardized teaching plan must be adapted to the individual’s beliefs and needs. Some of the most effective teaching can be done while care is being delivered.

 

DIF:    Cognitive Level: Application           REF:   Page 51          OBJ:   3 | 4

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Psychosocial Integrity

NOT:  CONCEPT(S): Clinical Judgment; Safety; Patient Education; Communication; Health Promotion

 

MULTIPLE RESPONSE

 

1. Which item(s) would be considered characteristic of the cognitive domain level of learning? (Select all that apply.)

a.	A patient’s opinion regarding wellness
b.	Basic mathematical formulas learned in grade school
c.	Incorporation of a person’s previous experiences and perceptions
d.	Skill demonstration using a step-by-step approach
e.	Relationship between prior experiences and new concepts

 

 

ANS:  B, C, E

Basic mathematical formulas learned previously, incorporating a person’s previous experiences and perceptions, and a relationship between prior experiences and new concepts characterize the cognitive domain level of learning. A patient’s opinion regarding wellness is an example of the affective domain. Skill demonstration using a step-by-step approach is an example of the psychomotor domain.

 

DIF:    Cognitive Level: Comprehension     REF:   Page 49          OBJ:   1

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Safe, Effective Care Environment

NOT:  CONCEPT(S): Patient Education; Communication

 

2. The nurse is preparing to instruct a patient and his wife on technique and importance of assessing pulse prior to taking heart medication. Which principle(s) of learning would be appropriate in this situation? (Select all that apply.)

a.	The learning environment
b.	The patient’s and wife’s learning styles
c.	The objectives/goal statements listed on the patient’s care plan
d.	The patient’s financial ability to purchase the medication
e.	The patient’s understanding of the seriousness of his illness

 

 

ANS:  A, B, C, E

Learning environment, learning style, listing clear objectives and goal statements, and understanding the seriousness of the situation are all principles of learning. Financial ability is not a principle of learning, but should be an important consideration and assessment when preparing for discharge of the patient and future compliance of the treatment regimen.

 

DIF:    Cognitive Level: Application           REF:   Page 50 | Page 51

OBJ:   3 | 4                TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Patient Education; Communication; Health Promotion

 

3. The nurse is writing a teaching plan for a 30-year-old patient who has AIDS. Which objective(s) is/are written in the correct format? (Select all that apply.)

a.	The patient will state adverse effects of the daily medications before discharge.
b.	The patient will correctly fill the daily medication pillbox with the correct medications in the appropriate time slots prior to discharge.
c.	The patient will adjust the medications accordingly.
d.	The patient will schedule an appointment with the infectious disease physician before discharge.
e.	The patient will have lab tests performed regularly.

 

 

ANS:  A, B, D

Each of correct objectives noted are measurable and specific.

 

DIF:    Cognitive Level: Analysis                REF:   Page 56 | Page 57

OBJ:   3 | 4 | 6            TOP:   Nursing Process Step: Planning

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Patient Education

 

4. Which action(s) by the nurse can foster patient responsibility for adhering to the therapeutic regimen? (Select all that apply.)

a.	Assessing the patient’s readiness to learn
b.	Determining the patient’s level of understanding of content
c.	Determining the patient’s education level and learning style
d.	Maintaining an aloof attitude toward presented content
e.	Documenting expected outcomes independently

 

 

ANS:  A, B, C

The nurse should assess the patient’s readiness to learn when teaching the patient. The nurse should determine the patient’s level of understanding of the content and the patient’s education level and learning style when teaching the patient. The nurse should portray a positive attitude when teaching the patient. Goals should be mutually written with the patient.

 

DIF:    Cognitive Level: Comprehension     REF:   Page 56          OBJ:   4

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Safe, Effective Care Environment

NOT:  CONCEPT(S): Clinical Judgment; Patient Education; Care Coordination; Communication; Health Promotion

 

5. What should the nurse include during discharge in addition to verbal instructions? (Select all that apply.)

a.	Written instructions for the patient’s reference
b.	A phone number of the provider or hospital unit for follow-up questions
c.	Written instructions for monitoring of parameters used to evaluate therapy
d.	Documentation in the nurse’s discharge notes of the nursing and collaborative problems that require continued monitoring and intervention
e.	Identification of the patient’s unreasonable expectations of therapy

 

 

ANS:  A, B, C, D

Learning is an ongoing process. Verbal instructions should be followed up with instructions in writing. Patients should be given a contact number for future reference. Written instructions for monitoring of parameters used to evaluate therapy should be given to the patient. Documentation is an essential part of validating the patient’s understanding of the instructions provided. Although identifying the patient’s expectations will affect the outcome, they are not part of the discharge planning documentation.

 

DIF:    Cognitive Level: Application           REF:   Page 50          OBJ:   5 | 6

TOP:   Nursing Process Step: Evaluation

MSC:  NCLEX Client Needs Category: Safe, Effective Care Environment

NOT:  CONCEPT(S): Clinical Judgment; Patient Education; Care Coordination; Communication; Health Promotion

 

6. Which action(s) would let the nurse know that the patient has mastered a psychomotor skill? (Select all that apply.)

a.	Describe the process verbally.
b.	Write a description of the process.
c.	Give a reciprocal demonstration of the process.
d.	Ask questions about the process.
e.	Demonstrate the process to another person while the nurse supervises.
f.	State whether the patient feels the process has been mastered.

 

 

ANS:  C, D

Having the patient demonstrate the process to the nurse or to another person is the best way to ensure that he can perform the skill correctly. Having the patient describe the process or write a description of the process is not sufficient. Asking questions may reinforce learning but may also mask some deficiencies. Asking the patient whether he feels he has mastered the process is not sufficient.

 

DIF:    Cognitive Level: Comprehension     REF:   Page 51          OBJ:   1 | 6

TOP:   Nursing Process Step: Evaluation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Patient Education; Care Coordination; Communication; Health Promotion

 

7. The nurse and patient are participating in cooperative goal setting regarding drug therapy. The nurse is aware that it is imperative to encourage the patient to perform which task(s)? (Select all that apply.)

a.	Contact the hospital for advice regarding discontinuation of medication.
b.	Keep records of essential data needed to evaluate prescribed therapy.
c.	See the health care provider regularly.
d.	Avoid community-based agencies for assistance.
e.	Monitor parameters used to evaluate therapy.

 

 

ANS:  B, C, E

An attitude of shared input into the goals and outcomes can encourage the patient into a therapeutic alliance. Therefore, the patient should be taught to help monitor the parameters used to evaluate therapy, keep records of essential data, and contact the health care provider for advice rather than alter or discontinue the medication entirely. The health care provider, not the hospital, should be contacted. In the event that the patient, family, or significant others do not understand all aspects of the continuing therapy prescribed, they may be referred to a community-based agency for help in achieving long-term health care requirements.

 

DIF:    Cognitive Level: Application           REF:   Page 57          OBJ:   3 | 4

TOP:   Nursing Process Step: Planning

MSC:  NCLEX Client Needs Category: Safe, Effective Care Environment

NOT:  CONCEPT(S): Clinical Judgment; Patient Education; Care Coordination; Communication; Health Promotion

 

 

 

 

Chapter 27: Drugs Used to Treat Heart Failure

Clayton/Willihnganz: Basic Pharmacology for Nurses, 17th Edition

 

MULTIPLE CHOICE

 

1. Which drug will be administered to a patient being admitted with severe digoxin intoxication?

a.	Amiodarone (Cordarone)
b.	Spironolactone (Aldactone)
c.	Digoxin immune Fab (Digibind)
d.	Digitalis glycoside

 

 

ANS:  C

The antidote for digoxin intoxication is digoxin immune Fab (Digibind). Amiodarone is an antidysrhythmic and would not treat digoxin intoxication. Spironolactone is a diuretic and does not treat digoxin intoxication. Giving more of the same type of drug does not treat drug intoxication.

 

DIF:    Cognitive Level: Comprehension     REF:   Page 429        OBJ:   3 | 4

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Safety

 

2. The nurse is caring for a 3-year-old girl who has a congenital heart anomaly. The patient’s current medications include digoxin and furosemide (Lasix). The apical pulse rate is 100 beats/min. Which action will the nurse take?

a.	Administer the medication.
b.	Contact the pediatric cardiologist for further orders.
c.	Hold the digoxin.
d.	Request that another unit nurse assess the child.

 

 

ANS:  A

A pulse rate of 100 beats/min in a child who is 3 years old is considered acceptable. Administration of the medication is appropriate. There is no indication for contacting the cardiologist, holding the dose, or requesting further assessment because this is within the expected range.

 

DIF:    Cognitive Level: Application           REF:   Page 428        OBJ:   5

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Safety

 

3. An older adult male patient with long-term heart failure has presented for an office visit. The nurse obtains information that he has recently begun taking St. John’s wort. What results with the use of this herbal supplement?

a.	Digoxin toxicity
b.	Altered potassium electrolyte balance
c.	Reduced therapeutic benefits of digoxin
d.	Enhanced digoxin effectiveness without producing toxicity

 

 

ANS:  C

St. John’s wort is a drug that may reduce therapeutic benefits of digoxin. St. John’s wort has the opposite effect on digoxin and does not affect electrolytes.

 

DIF:    Cognitive Level: Application           REF:   Page 430        OBJ:   3 | 5

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Safety

 

4. The nurse is to administer digoxin to an 18-month-old patient who weighs 16.5 lb. Guidelines for administration read as follows: 0.0075 to 0.010 mg/kg/day. Which is a safe medication dosage?

a.	0.05 mg
b.	0.12 mg
c.	0.074 mg
d.	0.75 mg

 

 

ANS:  C

16.5 lb converts to 7.5 kg; 7.5 kg ´ 0.0075 mg = 0.05625; 7.5 kg ´ 0.010 mg = 0.075 mg; 0.074 mg is the only answer within the safe dosage range. Values of 0.05 mg, 0.12 mg, and 0.75 mg are too large.

 

DIF:    Cognitive Level: Application           REF:   Page 429        OBJ:   3 | 5

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Safe, Effective Care Environment

NOT:  CONCEPT(S): Clinical Judgment; Safety

 

5. The nurse monitors a patient receiving digoxin closely for toxicity when which other medication is prescribed?

a.	Potassium supplements
b.	Furosemide (Lasix)
c.	Acetylsalicylic acid (aspirin)
d.	Antibiotics

 

 

ANS:  B

Furosemide is a potassium-depleting diuretic. Low potassium levels potentiate digoxin toxicity. Taking potassium supplements with a diuretic prevents digoxin toxicity. Aspirin and antibiotics do not affect digoxin levels.

 

DIF:    Cognitive Level: Knowledge            REF:   Page 430        OBJ:   3 | 4

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Safety

 

6. Which is the initial manifestation of digoxin toxicity in children?

a.	Hallucinations
b.	Weakness
c.	Atrial dysrhythmia
d.	Diuresis

 

 

ANS:  C

In children, digoxin toxicity is often first detected by the development of atrial dysrhythmias. Hallucinations, weakness, and diuresis are not initial manifestations of digoxin toxicity in children.

 

DIF:    Cognitive Level: Knowledge            REF:   Page 429        OBJ:   4 | 5

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Safety

 

7. Which agents stimulate the heart to increase the force of contractions, thereby increasing cardiac output?

a.	Inotropic
b.	Chronotropic
c.	Isotonic
d.	Isopropyl

 

 

ANS:  A

Inotropic agents stimulate the heart to increase the force of contractions, thus boosting cardiac output. Chronotropic agents are given to increase heart rate. Isotonic agents have the same pH as body fluids. Isopropyl agents include rubbing alcohol.

 

DIF:    Cognitive Level: Comprehension     REF:   Page 421        OBJ:   3

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Perfusion

 

8. Which drug is used to obtain vasodilation in the treatment of chronic heart failure?

a.	ACTH
b.	ACE inhibitors
c.	ARBs
d.	ANB agents

 

 

ANS:  B

Angiotensin converting enzyme (ACE) inhibitors are the mainstays of oral vasodilator therapy for treating chronic heart failure. ACTH is adrenocorticotropic hormone, secreted by the anterior pituitary to stimulate the adrenal cortex. ARBs are angiotensin reuptake blockers, used for the treatment of hypertension. ANB agents are adrenergic neuron blocking agents, such as guanethidine, given for the treatment of hypertension.

 

DIF:    Cognitive Level: Comprehension     REF:   Page 427        OBJ:   3

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Perfusion

 

9. Which action of ACE inhibitors results in effective treatment of heart failure?

a.	Increased afterload
b.	Increased aldosterone
c.	Increased preload
d.	Increased cardiac output

 

 

ANS:  D

The therapeutic outcome of ACE inhibitors in heart failure is to improve cardiac output. ACE inhibitors reduce afterload, inhibit the secretion of aldosterone, and reduce preload.

 

DIF:    Cognitive Level: Comprehension     REF:   Page 427        OBJ:   3

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Perfusion

 

10. The nurse is providing teaching to a patient with heart failure who has been prescribed nifedipine, a calcium channel blocker. Which statement by the nurse is accurate?

a.	“This medication dilates your coronary arteries.”
b.	“This medication will help your kidneys get rid of fluid.”
c.	“This medication reduces volume returning to your heart so it doesn’t overstretch.”
d.	“This medication reduces the resistance your heart has to pump against.”

 

 

ANS:  D

This medication reduces afterload or the resistance against which the heart has to pump. This medication is not used in heart failure for this reason, does not have a diuretic effect, and does not reduce volume.

 

DIF:    Cognitive Level: Application           REF:   Page 422        OBJ:   3 | 5

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Perfusion

 

11. Which instruction by the nurse will be included when teaching an adult patient about digoxin (Lanoxin) for management of heart failure?

a.	“Report nausea and vomiting to your health care provider.”
b.	“Decrease the amount of high potassium foods you eat.”
c.	“Omit your dose of digoxin if your pulse is 60 beats/min.”
d.	“Visual disturbances are common adverse effects.”

 

 

ANS:  A

Nausea and vomiting are serious adverse effects indicative of toxicity. Low potassium levels can cause toxicity; adequate intake of potassium is necessary. The dose is withheld if the pulse rate is less than 60 beats/min in adults. Visual disturbances are not common adverse effects.

 

DIF:    Cognitive Level: Application           REF:   Page 429 | Page 430

OBJ:   3 | 4                TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Patient Education; Safety

 

12. Which nursing assessment is most important to determine fluid status for a patient with heart failure?

a.	Auscultation of lungs
b.	Daily weights
c.	Intake and output
d.	Measurement of abdominal girth

 

 

ANS:  B

Daily weights are the best indicator of fluid gain or loss. Auscultation of lungs, measurement of intake and output, and measurement of abdominal girth are not the best indicators of fluid status.

 

DIF:    Cognitive Level: Application           REF:   Page 425        OBJ:   1 | 2 | 5

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Fluid and Electrolyte Balance

 

13. A patient with altered cardiac function is being assessed by the nurse. When auscultating lung sounds, the nurse will assist this patient into a _____ position.

a.	prone
b.	supine
c.	Sims
d.	Fowler’s

 

 

ANS:  D

Lung fields are assessed in a sitting (Fowler’s) position to detect abnormal lung sounds. Prone, supine, and Sims positions are not the best positions to detect abnormal lung sounds.

 

DIF:    Cognitive Level: Application           REF:   Page 425        OBJ:   5

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment

 

14. The nurse transcribes a new order for a daily diuretic on a patient diagnosed with congestive heart failure. The nurse will schedule this medication

a.	in the morning.
b.	after lunch.
c.	with dinner.
d.	at bedtime.

 

 

ANS:  A

Diuretics should be taken in the morning to avoid night time diuresis.

 

DIF:    Cognitive Level: Application           REF:   Page 426        OBJ:   3 | 5

TOP:   Nursing Process Step: Planning

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Elimination

 

MULTIPLE RESPONSE

 

1. The nurse is assessing an emergency department patient who was recently discharged following a myocardial infarction (MI). Which symptom(s) would the nurse observe in this patient with left ventricular systolic failure? (Select all that apply.)

a.	Reports of recent weight loss
b.	Complaints of peripheral edema
c.	Diminished exercise tolerance
d.	Shortness of breath with activity
e.	Blood pressure elevation

 

 

ANS:  C, D

Early clinical symptoms of left ventricular failure are decreased exercise tolerance and poor perfusion to peripheral tissues. Patients who develop left ventricular systolic failure as a result of MI have acute shortness of breath. Weight gain is more likely to be reported because of edema in diastolic failure. Patients who develop left ventricular systolic failure as a result of MI have shock with little peripheral edema and hypotension.

 

DIF:    Cognitive Level: Comprehension     REF:   Page 419        OBJ:   1

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Perfusion; Gas Exchange

 

2. Before administering digoxin (Lanoxin), the nurse takes the adult patient’s apical pulse for 1 full minute. What additional nursing consideration(s) will be taken before administration of the medication? (Select all that apply.)

a.	Review of the digoxin blood level
b.	Administration of the medication with pulse less than 60 beats/min
c.	Review of serum electrolytes, liver, and kidney function studies
d.	Administration of the medication with a pulse of 110 beats/min
e.	Obtaining baseline patient assessment data, including lung sounds, vital signs, and weight

 

 

ANS:  A, C, E

Before administering digoxin, the nurse should review digoxin levels, review baseline diagnostic data (electrolytes, liver, and kidney function tests), obtain appropriate physical assessments for heart failure patients, and verify that pulse rate is between 60 and 100 beats/min.

 

DIF:    Cognitive Level: Analysis                REF:   Page 428        OBJ:   3 | 5

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Safety

 

3. Which action(s) will the nurse take when caring for a patient with heart failure? (Select all that apply.)

a.	Administer diuretics at bedtime.
b.	Assess electrolyte levels.
c.	Report daily weight fluctuations.
d.	Encourage sodium intake.
e.	Maintain skin hygiene.

 

 

ANS:  B, C, E

Ongoing assessment of electrolyte levels is critical when caring for a patient with heart failure. Weight gains and losses are the single best indicator of fluid gain or loss. The maintenance of skin care and changing of positions are essential to prevent skin breakdown. Diuretics should be given in the morning and afternoon, not at bedtime, because this would interfere with sleep. Heart failure patients are prone to edema, which interferes with vascular return in the peripheral areas. Sodium restriction is one way of controlling edema.

 

DIF:    Cognitive Level: Application           REF:   Page 424 | Page 425

OBJ:   2 | 5                TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Health Promotion and Maintenance

NOT:  CONCEPT(S): Clinical Judgment; Fluid and Electrolyte Balance; Skin Integrity

 

4. Which contributing factor(s) to heart failure is/are modifiable? (Select all that apply.)

a.	Hypertension
b.	Addiction to smoking
c.	Genetic history
d.	Exercise tolerance
e.	Age

 

 

ANS:  A, B, D

Hypertension, smoking, and diminished exercise tolerance are contributing factors to atherosclerosis, which can be modified with changes in behavior and the assistance of medications. Genetic history and age are not modifiable factors.

 

DIF:    Cognitive Level: Comprehension     REF:   Page 421        OBJ:   1 | 5

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Health Promotion and Maintenance

NOT:  CONCEPT(S): Clinical Judgment; Safety; Health Promotion

 

5. A patient with heart failure has been prescribed nesiritide (Natrecor). Which statement(s) is/are true regarding this medication? (Select all that apply.)

a.	It increases preload.
b.	Cardiac ventricles secrete this hormone in response to fluid overload.
c.	It suppresses aldosterone.
d.	It promotes norepinephrine secretion.
e.	It causes vasodilation.

 

 

ANS:  B, C, E

Nesiritide is a hormone normally secreted by the cardiac ventricles in response to fluid and pressure overload, suppresses aldosterone, and causes vasodilation. Nesiritide does not increase preload or promote norepinephrine secretion.

 

DIF:    Cognitive Level: Comprehension     REF:   Page 427        OBJ:   3

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Perfusion

 

6. Which statement(s) about vasodilators is/are true? (Select all that apply.)

a.	They reduce systemic vascular resistance.
b.	They increase afterload.
c.	They reduce preload.
d.	They decrease pulmonary congestion.
e.	They increase tissue perfusion to muscles and organs.
f.	They increase the volume of blood returning to the heart.

 

 

ANS:  A, C, D, E

Vasodilators reduce systemic vascular resistance (afterload), decrease preload, relieve pulmonary congestion, and increase tissue perfusion to muscles and vital organs. Vasodilators reduce systemic vascular resistance (afterload) and reduce preload so that the high volume of blood returning to the heart is decreased.

 

DIF:    Cognitive Level: Comprehension     REF:   Page 421        OBJ:   N/A

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Perfusion

 

7. The nurse is providing education to a patient with altered cardiac function. When instructing this patient the nurse will encourage (Select all that apply.)

a.	alcohol consumed in moderation.
b.	use of salt substitute.
c.	regular, mild exercise.
d.	good skin care.
e.	stress reduction.

 

 

ANS:  C, D, E

Regular, mild exercise; good skin care; and stress reduction should be encouraged with a patient with altered cardiac function. Alcohol intake should be eliminated from the diet. Salt substitutes are high in potassium, so use must be limited.

 

DIF:    Cognitive Level: Application           REF:   Page 426        OBJ:   5

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Perfusion; Skin Integrity; Health Promotion