WorksheetsNursing Assessment and Interventions
Total questions: 50
Worksheet time: 25mins
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
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
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
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
Which lab test is most specific for myocardial injury?
BNP
Troponin
CBC
Potassium
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
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
Which finding would indicate the treatment for heart failure is effective?
. Stable or decreased daily weight
BP of 180/100
Increased BNP
Worsening crackles
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
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
A nurse is caring for a patient on hydrochlorothiazide (HCTZ). Which lab value should the nurse monitor most closely?
Hemoglobin
Potassium
Calcium
Albumin
A client with left-sided heart failure reports shortness of breath and is coughing up pink frothy sputum. What condition is this most likely?
Pericarditis
Pleural effusion
Pulmonary edema
Pneumothorax
. A patient with a history of atrial fibrillation undergoes ablation. What is the purpose of this procedure?
Replace a faulty valve
Destroy heart tissue causing arrhythmia
. Place a pacemaker
Relieve fluid overload
. A nurse is caring for a patient taking spironolactone. What electrolyte imbalance should the nurse monitor for?
Hyperkalemia
Hypokalemia
Hyponatremia
Hypercalcemia
Which medication should the nurse question giving to a patient with a potassium level of 5.8?
Furosemide
Spironolactone
Digoxin
Atropine
A nurse suspects cardiac tamponade. What assessment finding would support this?
Clear breath sounds
Muffled heart sounds
Bounding pulses
Elevated urine output
A patient is diagnosed with coarctation of the aorta. What is the nurse most likely to assess?
. High BP in upper extremities and low BP in lower extremities
Bradycardia
Wide pulse pressure
Cyanosis
Which action is most important when administering nitroglycerin to a client with chest pain?
Elevate the head of the bed
Check the blood pressure first
Administer with food
Have the client drink water after
A patient on metoprolol complains of dizziness and a pulse of 52 bpm. What is the best action by the nurse?
Administer the medication
Hold the medication and notify the provider
Administer oxygen
Give a fluid bolus
Which patient teaching is most important when starting lisinopril?
Avoid potassium-rich foods
Rise slowly from sitting or lying
Increase sodium intake
Report dry mouth immediately
A nurse is caring for a patient with heart failure. Which of the following indicates the patient understands fluid restriction education?
I will drink 3 liters of water to stay hydrated.”
“I should weigh myself once a week.”
“I will keep track of how much I drink every day.”
Salt doesn’t affect how much fluid I retain.”
A client with atrial fibrillation is at risk for stroke due to:
Low heart rate
Blood pooling in atria leading to clots
High blood pressure
Inflammation of the heart valves
A client with chest pain is prescribed aspirin. What is the main purpose of this medication in this case?
Reduce fever
Reduce anxiety
Prevent clot formation
Dilate coronary arteries
A nurse is educating a patient about daily aspirin. Which of the following would require notifying the provider?
History of peptic ulcer disease
Previous shoulder injury
. Family history of diabetes
Occasional headaches
Which finding would the nurse report immediately in a patient with HF?
2+ peripheral edema
Weight gain of 3 pounds overnight
Pulse 92 bpm
Fatigue with walking
A patient’s BNP level is 850 pg/mL. How should the nurse interpret this
Normal finding
Worsening heart failure
Kidney dysfunction
Early dehydration
Which intervention is most appropriate for a patient on furosemide?
Encourage sodium intake
Monitor potassium levels and I&O
Avoid all dairy products
Administer at bedtime
A patient has atrial fibrillation and is prescribed heparin. What is the purpose of this medication?
Prevent blood clots
Lower heart rate
Reduce blood pressure
Stop bleeding
A nurse is reviewing a patient's echocardiogram. The ejection fraction is 35%. What does this indicate?
Normal heart function
Mild dehydration
Poor cardiac output from heart failure
Acute myocardial infarction
A client on digoxin has a potassium level of 2.9. What is the nurse’s priority?
Notify provider—hypokalemia increases digoxin toxicity risk
Encourage deep breathing
Hold digoxin for 24 hours
Administer calcium
A patient receiving amlodipine reports swelling in their ankles. What is the most appropriate nursing action?
Encourage fluid intake
Notify the provider—edema is a known side effect
Stop the medication
Reassure that this is not related
A client with bradycardia is prescribed atropine. What is the intended effect of this medication?
Lower blood pressure
Increase heart rate
Improve oxygen saturation
Reduce fever
A client with severe chest pain has a blood pressure of 82/50. Which medication should the nurse question?
Aspirin
Morphine
Oxygen
Nitroglycerin
A nurse is giving discharge instructions to a patient with left-sided heart failure. What statement indicates understanding?
“If I gain 5 lbs in a week, that’s expected.”
“I’ll sit upright when I feel short of breath.”
I’ll drink extra fluids to prevent dehydration.”
“I’ll weigh myself once a month.”
A patient on lisinopril reports a persistent dry cough. What is the best action?
Advise the patient to increase fluids
Notify the provider—may need to switch to ARB
Give a cough suppressant
Reassure the patient it's normal and permanent
A nurse is caring for a patient with heart failure. Which diet order should the nurse question?
1,500 mg sodium restriction
Fluid restriction
. Low-fat diet
High-sodium diet
The nurse is evaluating a patient on valsartan. Which of the following findings requires further assessment?
Potassium level of 5.6 mEq/L
BP of 130/82
Pulse 76 bpm
Mild dizziness when standing
A patient receiving diuretics for heart failure reports dizziness when standing up. What is the priority intervention?
Teach the patient to rise slowly from bed or chair
Restrict all fluid intake
Increase the medication dose
Stop the diuretic
A nurse is caring for a client with suspected atherosclerosis. What is the expected pathophysiology?
Hardening of capillary beds
Valve regurgitation
Plaque buildup in arteries
Fluid in the pericardium
A patient with a history of MI is prescribed metoprolol. What is the purpose of this medication?
Reduce cardiac workload by lowering HR and BP
Increase cardiac output
Prevent clot formation
Improve kidney function
. A patient with chronic hypertension is being monitored for heart failure. Which compensatory mechanism should the nurse expect?
Bradycardia
Ventricular hypertrophy
Hypovolemia
Decreased aldosterone levels
Which of the following is the correct anatomical location to auscultate the tricuspid valve?
2nd intercostal space, right sternal border
4th intercostal space, left sternal border
5th intercostal space, midclavicular line
2nd intercostal space, left sternal border
A client’s EKG shows a heart rate of 52 bpm. They feel dizzy but alert. Which medication should the nurse anticipate administering?
. Metoprolol
Atropine
Lisinopril
Digoxin
Which of the following symptoms would most likely indicate left-sided heart failure?
JVD and ascites
Dyspnea and crackles
Dependent edema
Weight gain
A patient on heparin is bleeding excessively. What is the priority intervention?
Apply heat
Give vitamin K
Administer protamine sulfate
Encourage fluids
The nurse is assessing a client with pericardial effusion. Which complication is the nurse most concerned about
Cardiac tamponade
Stroke
Myocardial infarction
Aortic dissection
Which patient is at greatest risk for developing heart failure?
35-year-old with asthma
45-year-old with peptic ulcer disease
65-year-old with uncontrolled hypertension
50-year-old with hypothyroidism
. The nurse is teaching about digoxin. Which statement indicates the need for further teaching?
“I will check my pulse before taking this.”
If I feel nauseated, I will keep taking the medication.”
I’ll report vision changes.”
“I will call my provider if my pulse is below 60.”
A patient has an ejection fraction of 70%. What does this indicate?
Poor heart function
Severe HF
Normal cardiac output
Cardiac tamponade
Which of the following nursing actions is most important before giving digoxin?
Monitor oxygen saturation
Check blood glucose
. Assess apical pulse for 1 full minute
Measure respiratory rate
