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Nursing Assessment and Interventions

Total questions: 50

Worksheet time: 25mins

Name
Class
Date
1.

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

a)

A. 2nd intercostal space, right sternal border

b)

2nd intercostal space, left sternal border

c)

4th intercostal space, left sternal border

d)

5th intercostal space, midclavicular line

2.

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

a)

Cardiac tamponade

b)

Pericardial effusion

c)

Intermittent claudication

d)

Congestive heart failure

3.

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

a)

Crackles

b)

Jugular vein distension

c)

Dyspnea

d)

Pulmonary edema

4.

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

a)

Give antiemetic medication

b)

. Give antiemetic medication

c)

Hold the dose and check digoxin levels

d)

Reassure the client this is normal

5.

Which lab test is most specific for myocardial injury?

a)

BNP

b)

Troponin

c)

CBC

d)

Potassium

6.

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

a)

Start a high-protein diet

b)

Encourage coughing

c)

Provide a low-sodium meal

d)

Place the client in High Fowler’s position

7.

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

a)

Ask the client to chew the tablet

b)

Instruct the client to sit down

c)

Encourage fluids

d)

Wait 1 hour before reassessing

8.

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

a)

. Stable or decreased daily weight

b)

BP of 180/100

c)

Increased BNP

d)

Worsening crackles

9.

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

a)

Potassium 4.0

b)

Blood pressure 88/56

c)

Sodium 138

d)

Pulse 80 bpm

10.

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

a)

Bounding peripheral pulses

b)

Warm, flushed extremities

c)

. Cool extremities and fatigue

d)

Increased urine output

11.

A nurse is caring for a patient on hydrochlorothiazide (HCTZ). Which lab value should the nurse monitor most closely?

a)

Hemoglobin

b)

Potassium

c)

Calcium

d)

Albumin

12.

A client with left-sided heart failure reports shortness of breath and is coughing up pink frothy sputum. What condition is this most likely?

a)

Pericarditis

b)

Pleural effusion

c)

Pulmonary edema

d)

Pneumothorax

13.

. A patient with a history of atrial fibrillation undergoes ablation. What is the purpose of this procedure?

a)

Replace a faulty valve

b)

Destroy heart tissue causing arrhythmia

c)

. Place a pacemaker

d)

Relieve fluid overload

14.

. A nurse is caring for a patient taking spironolactone. What electrolyte imbalance should the nurse monitor for?

a)

Hyperkalemia

b)

Hypokalemia

c)

Hyponatremia

d)

Hypercalcemia

15.

Which medication should the nurse question giving to a patient with a potassium level of 5.8?

a)

Furosemide

b)

Spironolactone

c)

Digoxin

d)

Atropine

16.

A nurse suspects cardiac tamponade. What assessment finding would support this?

a)

Clear breath sounds

b)

Muffled heart sounds

c)

Bounding pulses

d)

Elevated urine output

17.

A patient is diagnosed with coarctation of the aorta. What is the nurse most likely to assess?

a)

. High BP in upper extremities and low BP in lower extremities

b)

Bradycardia

c)

Wide pulse pressure

d)

Cyanosis

18.

Which action is most important when administering nitroglycerin to a client with chest pain?

a)

Elevate the head of the bed

b)

Check the blood pressure first

c)

Administer with food

d)

Have the client drink water after

19.

A patient on metoprolol complains of dizziness and a pulse of 52 bpm. What is the best action by the nurse?

a)

Administer the medication

b)

Hold the medication and notify the provider

c)

Administer oxygen

d)

Give a fluid bolus

20.

Which patient teaching is most important when starting lisinopril?

a)

Avoid potassium-rich foods

b)

Rise slowly from sitting or lying

c)

Increase sodium intake

d)

Report dry mouth immediately

21.

A nurse is caring for a patient with heart failure. Which of the following indicates the patient understands fluid restriction education?

a)

I will drink 3 liters of water to stay hydrated.”

b)

“I should weigh myself once a week.”

c)

“I will keep track of how much I drink every day.”

d)

Salt doesn’t affect how much fluid I retain.”

22.

A client with atrial fibrillation is at risk for stroke due to:

a)

Low heart rate

b)

Blood pooling in atria leading to clots

c)

High blood pressure

d)

Inflammation of the heart valves

23.

A client with chest pain is prescribed aspirin. What is the main purpose of this medication in this case?

a)

Reduce fever

b)

Reduce anxiety

c)

Prevent clot formation

d)

Dilate coronary arteries

24.

A nurse is educating a patient about daily aspirin. Which of the following would require notifying the provider?

a)

History of peptic ulcer disease

b)

Previous shoulder injury

c)

. Family history of diabetes

d)

Occasional headaches

25.

Which finding would the nurse report immediately in a patient with HF?

a)

2+ peripheral edema

b)

Weight gain of 3 pounds overnight

c)

Pulse 92 bpm

d)

Fatigue with walking

26.

A patient’s BNP level is 850 pg/mL. How should the nurse interpret this

a)

Normal finding

b)

Worsening heart failure

c)

Kidney dysfunction

d)

Early dehydration

27.

Which intervention is most appropriate for a patient on furosemide?

a)

Encourage sodium intake

b)

Monitor potassium levels and I&O

c)

Avoid all dairy products

d)

Administer at bedtime

28.

A patient has atrial fibrillation and is prescribed heparin. What is the purpose of this medication?

a)

Prevent blood clots

b)

Lower heart rate

c)

Reduce blood pressure

d)

Stop bleeding

29.

A nurse is reviewing a patient's echocardiogram. The ejection fraction is 35%. What does this indicate?

a)

Normal heart function

b)

Mild dehydration

c)

Poor cardiac output from heart failure

d)

Acute myocardial infarction

30.

A client on digoxin has a potassium level of 2.9. What is the nurse’s priority?

a)

Notify provider—hypokalemia increases digoxin toxicity risk

b)

Encourage deep breathing

c)

Hold digoxin for 24 hours

d)

Administer calcium

31.

A patient receiving amlodipine reports swelling in their ankles. What is the most appropriate nursing action?

a)

Encourage fluid intake

b)

Notify the provider—edema is a known side effect

c)

Stop the medication

d)

Reassure that this is not related

32.

A client with bradycardia is prescribed atropine. What is the intended effect of this medication?

a)

Lower blood pressure

b)

Increase heart rate

c)

Improve oxygen saturation

d)

Reduce fever

33.

A client with severe chest pain has a blood pressure of 82/50. Which medication should the nurse question?

a)

Aspirin

b)

Morphine

c)

Oxygen

d)

Nitroglycerin

34.

A nurse is giving discharge instructions to a patient with left-sided heart failure. What statement indicates understanding?

a)

“If I gain 5 lbs in a week, that’s expected.”

b)

“I’ll sit upright when I feel short of breath.”

c)

I’ll drink extra fluids to prevent dehydration.”

d)

“I’ll weigh myself once a month.”

35.

A patient on lisinopril reports a persistent dry cough. What is the best action?

a)

Advise the patient to increase fluids

b)

Notify the provider—may need to switch to ARB

c)

Give a cough suppressant

d)

Reassure the patient it's normal and permanent

36.

A nurse is caring for a patient with heart failure. Which diet order should the nurse question?

a)

1,500 mg sodium restriction

b)

Fluid restriction

c)

. Low-fat diet

d)

High-sodium diet

37.

The nurse is evaluating a patient on valsartan. Which of the following findings requires further assessment?

a)

Potassium level of 5.6 mEq/L

b)

BP of 130/82

c)

Pulse 76 bpm

d)

Mild dizziness when standing

38.

A patient receiving diuretics for heart failure reports dizziness when standing up. What is the priority intervention?

a)

Teach the patient to rise slowly from bed or chair

b)

Restrict all fluid intake

c)

Increase the medication dose

d)

Stop the diuretic

39.

A nurse is caring for a client with suspected atherosclerosis. What is the expected pathophysiology?

a)

Hardening of capillary beds

b)

Valve regurgitation

c)

Plaque buildup in arteries

d)

Fluid in the pericardium

40.

A patient with a history of MI is prescribed metoprolol. What is the purpose of this medication?

a)

Reduce cardiac workload by lowering HR and BP

b)

Increase cardiac output

c)

Prevent clot formation

d)

Improve kidney function

41.

. A patient with chronic hypertension is being monitored for heart failure. Which compensatory mechanism should the nurse expect?

a)

Bradycardia

b)

Ventricular hypertrophy

c)

Hypovolemia

d)

Decreased aldosterone levels

42.

Which of the following is the correct anatomical location to auscultate the tricuspid valve?

a)

2nd intercostal space, right sternal border

b)

4th intercostal space, left sternal border

c)

5th intercostal space, midclavicular line

d)

2nd intercostal space, left sternal border

43.

A client’s EKG shows a heart rate of 52 bpm. They feel dizzy but alert. Which medication should the nurse anticipate administering?

a)

. Metoprolol

b)

Atropine

c)

Lisinopril

d)

Digoxin

44.

Which of the following symptoms would most likely indicate left-sided heart failure?

a)

JVD and ascites

b)

Dyspnea and crackles

c)

Dependent edema

d)

Weight gain

45.

A patient on heparin is bleeding excessively. What is the priority intervention?

a)

Apply heat

b)

Give vitamin K

c)

Administer protamine sulfate

d)

Encourage fluids

46.

The nurse is assessing a client with pericardial effusion. Which complication is the nurse most concerned about

a)

Cardiac tamponade

b)

Stroke

c)

Myocardial infarction

d)

Aortic dissection

47.

Which patient is at greatest risk for developing heart failure?

a)

35-year-old with asthma

b)

45-year-old with peptic ulcer disease

c)

65-year-old with uncontrolled hypertension

d)

50-year-old with hypothyroidism

48.

. The nurse is teaching about digoxin. Which statement indicates the need for further teaching?

a)

“I will check my pulse before taking this.”

b)

If I feel nauseated, I will keep taking the medication.”

c)

I’ll report vision changes.”

d)

“I will call my provider if my pulse is below 60.”

49.

A patient has an ejection fraction of 70%. What does this indicate?

a)

Poor heart function

b)

Severe HF

c)

Normal cardiac output

d)

Cardiac tamponade

50.

Which of the following nursing actions is most important before giving digoxin?

a)

Monitor oxygen saturation

b)

Check blood glucose

c)

. Assess apical pulse for 1 full minute

d)

Measure respiratory rate