Chapter 35 Evolve NCLEX Answers

1. 1.ID: 809426607

The nurse is administering a dose of digoxin (Lanoxin) to a patient with heart

failure (HF). The nurse would become concerned with the possibility of digitalis
toxicity if the patient reported which symptom(s)?

Muscle aches
Constipation
Pounding headache
Anorexia and nausea Correct
2. 2.ID: 809426661

The nurse is preparing to administer digoxin to a patient with heart failure. In

preparation, laboratory results are reviewed with the following findings: sodium
139 mEq/L, potassium 5.6 mEq/L, chloride 103 mEq/L, and glucose 106 mg/dL.
What should the nurse do next?

Withhold the daily dose until the following day.

Withhold the dose and report the potassium level. Correct
Give the digoxin with a salty snack, such as crackers.
Give the digoxin with extra fluids to dilute the sodium level.
3. 3.ID: 809426620

The nurse is caring for a patient newly diagnosed with heart failure. The patient is
to receive a first dose of digoxin (Lanoxin) 0.125 mg IV push. An ampule
containing 0.25 mg/mL is available. Calculate the number of milliliters the nurse
should draw up to administer this dose. ______ mL

This was the correct response:

0.5 mL

Rationale: 0.5 mL: 0.125 mg (dose desired) 0.25 mg/mL (dose available) = 0.5
mL

4. 4.ID: 809426625
 What is the priority assessment by the nurse caring for a patient receiving IV
nesiritide (Natrecor) to treat heart failure?

Urine output
Lung sounds
Blood pressure Correct
Respiratory rate
5. 5.ID: 809503140

A patient admitted with heart failure appears very anxious and complains of
shortness of breath. Which nursing actions would be appropriate to alleviate this
patient's anxiety (select all that apply)?

Administer ordered morphine sulfate. Correct

Position patient in a semi-Fowler's position. Correct
Position patient on left side with head of bed flat.
Instruct patient on the use of relaxation techniques. Correct
Use a calm, reassuring approach while talking to patient. Correct
6. 6.ID: 809426657

A male patient with a long-standing history of heart failure has recently qualified
for hospice care. What measure should the nurse now prioritize when providing
care for this patient?

Taper the patient off his current medications.

Continue education for the patient and his family.
Pursue experimental therapies or surgical options.
Choose interventions to promote comfort and prevent suffering.
Correct
7. 7.ID: 809426665

What should the nurse recognize as an indication for the use of dopamine
(Intropin) in the care of a patient with heart failure?

Acute anxiety
Hypotension and tachycardia Correct
Peripheral edema and weight gain
Paroxysmal nocturnal dyspnea (PND)
8. 8.ID: 809426637

A patient with a recent diagnosis of heart failure has been prescribed furosemide
(Lasix) in an effort to physiologically do what for the patient?

Reduce preload. Correct

Decrease afterload.
Increase contractility.
Promote vasodilation.
9. 9.ID: 809426663

A patient with a diagnosis of heart failure has been started on a nitroglycerin

patch by his primary care provider. What should this patient be taught to avoid?

High-potassium foods
Drugs to treat erectile dysfunction Correct
Nonsteroidal antiinflammatory drugs
Over-the-counter H2-receptor blockers
10. 10.ID: 809426600

A stable patient with acute decompensated heart failure (ADHF) suddenly

becomes dyspneic. Before positioning the patient on the bedside, what should the
nurse assess first?

Urine output
Heart rhythm
Breath sounds
Blood pressure Correct
11. 11.ID: 809503154

The patient has heart failure (HF) with an ejection fraction of less than 40%. What
core measures should the nurse expect to include in the plan of care for this
patient (select all that apply)?

Left ventricular function is documented. Correct

Controlling dysrhythmias will eliminate HF.
Prescription for digoxin (Lanoxin) at discharge
 Prescription for angiotensin-converting enzyme (ACE) inhibitor at
discharge Correct
Education materials about activity, medications, weight monitoring,
and what to do if symptoms worsen Correct
12. 12.ID: 809426092

After having an MI, the nurse notes the patient has jugular venous distention,
gained weight, developed peripheral edema, and has a heart rate of 108/minute.
What should the nurse suspect is happening?

ADHF
Chronic HF
Left-sided HF
Right-sided HF Correct
13. 13.ID: 809426667

Beyond the first year after a heart transplant, the nurse knows that what is a major
cause of death?

Infection
Acute rejection
Immunosuppression
Cardiac vasculopathy Correct
14. 14.ID: 809426669

The patient with chronic heart failure is being discharged from the hospital. What
information should the nurse emphasize in the patient's discharge teaching to
prevent progression of the disease to ADHF?

Take medications as prescribed. Correct

Use oxygen when feeling short of breath.
Only ask the physician's office questions.
Encourage most activity in the morning when rested.