Heart Failure NCLEX Guide

 

1. A 68-year-old patient with left-sided heart failure reports difficulty breathing when lying flat. Which term best describes this symptom?

A. Orthopnea

B. Dyspnea on exertion

C. Paroxysmal nocturnal dyspnea

D. Cheyne-Stokes respiration

Answer: A. Orthopnea
Explanation: Orthopnea is shortness of breath that occurs when lying flat, commonly seen in left-sided heart failure.

2. A patient with heart failure is prescribed furosemide. Which electrolyte imbalance should the nurse monitor closely?

A. Hyperkalemia

B. Hypokalemia

C. Hypercalcemia

D. Hypernatremia

Answer: B. Hypokalemia
Explanation: Furosemide, a loop diuretic, increases potassium excretion, so hypokalemia is the primary concern.

3. A nurse is caring for a patient with right-sided heart failure. Which assessment finding is expected?

A. Crackles in the lungs

B. Ascites

C. Pink frothy sputum

D. Pulmonary edema

Answer: B. Ascites
Explanation: Right-sided heart failure causes systemic congestion, leading to ascites, hepatomegaly, and peripheral edema.

4. The nurse teaches a patient with chronic heart failure about fluid restriction. Which patient statement indicates correct understanding?

A. "I should limit fluids to about 2 liters per day."

B. "I can drink as much water as I want since it’s healthy."

C. "I should avoid fluids completely."

D. "I should drink more fluids to help my kidneys."

Answer: A. "I should limit fluids to about 2 liters per day."
Explanation: Patients with heart failure are typically advised to restrict fluid intake to around 2 liters per day to prevent fluid overload.

5. A patient with heart failure is receiving digoxin. Which finding requires immediate nursing action?

A. Heart rate of 58 bpm

B. Nausea and vomiting

C. Blood pressure 128/78 mmHg

D. Serum potassium 4.0 mEq/L

Answer: B. Nausea and vomiting
Explanation: Nausea and vomiting may indicate digoxin toxicity, requiring prompt intervention.

6. A nurse assesses a patient with left-sided heart failure. Which finding is most concerning?

A. Bilateral crackles in lung bases

B. 1+ pitting edema in ankles

C. Fatigue after minimal exertion

D. Nocturia

Answer: A. Bilateral crackles in lung bases
Explanation: Crackles indicate pulmonary congestion, which may progress to pulmonary edema, making it the most concerning finding.

7. The nurse is evaluating teaching for a patient with heart failure prescribed ACE inhibitors. Which statement indicates a need for further teaching?

A. "I should rise slowly to avoid dizziness."

B. "I may develop a dry cough."

C. "I should stop the medication if I feel dizzy."

D. "I will have my kidney function checked regularly."

Answer: C. "I should stop the medication if I feel dizzy."
Explanation: Dizziness can occur due to hypotension, but the medication should not be stopped abruptly; the provider should be consulted first.

8. A patient with severe heart failure has jugular vein distention, crackles, and peripheral edema. Which priority nursing intervention should the nurse implement?

A. Restrict fluid intake

B. Elevate legs on pillows

C. Administer prescribed diuretics

D. Encourage ambulation

Answer: C. Administer prescribed diuretics
Explanation: Administering diuretics reduces fluid overload and is the priority intervention for decompensated heart failure.

9. Which dietary teaching is appropriate for a patient with heart failure?

A. Increase sodium to maintain fluid balance

B. Limit sodium intake to less than 2 grams per day

C. Eat high-sodium canned soups for energy

D. Restrict potassium-rich foods

Answer: B. Limit sodium intake to less than 2 grams per day
Explanation: Sodium restriction to less than 2 grams per day helps reduce fluid retention and worsening of heart failure.

10. A patient with decompensated heart failure is receiving IV furosemide. Which assessment finding indicates the medication is effective?

A. Decreased peripheral edema

B. Increased jugular vein distention

C. Increased shortness of breath

D. Weight gain of 1 kg in 24 hours

Answer: A. Decreased peripheral edema
Explanation: Diuretics help remove excess fluid, leading to decreased edema, weight loss, and improved breathing.