Nursing Assessment and Interventions

A nurse is auscultating heart sounds in a patient. Where should the nurse place the stethoscope to assess the mitral valve?

• A. 2nd intercostal space, right sternal border

• 2nd intercostal space, left sternal border

• 4th intercostal space, left sternal border

• 5th intercostal space, midclavicular line

Answer explanation

Rationale: The mitral valve is best heard at the 5th intercostal space, midclavicular line—the apex of the heart.

A patient comes in with complaints of leg pain during walking that goes away with rest. What condition should the nurse suspect?

• Cardiac tamponade

• Pericardial effusion

• Intermittent claudication

• Congestive heart failure

Answer explanation

Intermittent claudication is leg pain with activity caused by poor circulation, commonly from atherosclerosis.

The nurse is caring for a patient with right-sided heart failure. Which of the following symptoms would the nurse expect?

• Crackles

• Jugular vein distension

• Dyspnea

• Pulmonary edema

Answer explanation

JVD is a hallmark sign of right-sided heart failure due to systemic venous congestion.

A client taking digoxin reports seeing yellow halos and feeling nauseous. What should the nurse do first?
A. Administer the next dose as scheduled

• Give antiemetic medication

• . Give antiemetic medication

• Hold the dose and check digoxin levels

• Reassure the client this is normal

Answer explanation

These are signs of digoxin toxicity. Hold the dose and check serum levels immediately.

Which lab test is most specific for myocardial injury?

• BNP

• Troponin

• CBC

• Potassium

Answer explanation

Troponin is the most sensitive and specific biomarker for cardiac muscle injury like MI.

A client with pulmonary edema is sitting upright and gasping for air. What is the priority nursing intervention?

• Start a high-protein diet

• Encourage coughing

• Provide a low-sodium meal

• Place the client in High Fowler’s position

Answer explanation

High Fowler's position improves lung expansion and oxygenation in pulmonary edema.

The nurse is giving sublingual nitroglycerin to a client with chest pain. What should be the nurse’s next action?

• Ask the client to chew the tablet

• Instruct the client to sit down

• Encourage fluids

• Wait 1 hour before reassessing

Answer explanation

Nitroglycerin can cause dizziness and hypotension, so the patient should sit or lie down before taking it.

Which finding would indicate the treatment for heart failure is effective?

• . Stable or decreased daily weight

• BP of 180/100

• Increased BNP

• Worsening crackles

Answer explanation

: Daily weight is the best indicator of fluid retention or loss. Weight stabilization = effective treatment.

Tags

NGSS.HS-LS1-3

A nurse reviews a medication order for lisinopril. What finding would cause concern before administration?

• Potassium 4.0

• Blood pressure 88/56

• Sodium 138

• Pulse 80 bpm

Answer explanation

Lisinopril lowers blood pressure. A BP of 88/56 is too low, and the med should be held.

A patient has symptoms of decreased cardiac output. What would the nurse expect to find?

• Bounding peripheral pulses

• Warm, flushed extremities

• . Cool extremities and fatigue

• Increased urine output

Answer explanation

Decreased CO reduces perfusion to tissues, leading to fatigue and cool extremities.