Question

Which symptom listed below would not typically be observed following the administration of IV furosemide to a patient with congestive heart failure?

Answer 1

Correct Answers:

Decreased pain

Rationale :

🩺Furosemide, a loop diuretic, is commonly used to manage fluid overload in conditions such as congestive heart failure.

💧Its expected effects include increased urine output, reduced edema, and lowered blood pressure due to its diuretic action.

⚠️However, it does not directly alleviate pain, making this an unexpected outcome after administration.

🧪Monitoring the patient for electrolyte imbalances and fluid loss is essential, but pain relief would require different interventions.

📌Core Message

Furosemide is expected to cause diuresis, reduce edema, and lower blood pressure, but it does not relieve pain.

Answer 2

Correct Answers:

Obesity

Rationale :

⚖️Obesity is a modifiable risk factor for coronary artery disease and can be improved with lifestyle changes such as diet and exercise.

🧬In contrast, age, gender, and heredity are non-modifiable factors that cannot be altered by personal choices.

❤️Reducing body weight helps lower cholesterol levels, blood pressure, and insulin resistance, which are all risk factors for CAD.

🏃Addressing modifiable risks like obesity significantly contributes to cardiovascular health promotion and disease prevention.

📌Core Message

Only modifiable factors like obesity can be targeted to reduce the risk of coronary artery disease.

Answer 3

Correct Answers:

History of cerebral hemorrhage

Rationale :

🧠A history of cerebral hemorrhage is a strong contraindication to t-PA use due to the elevated risk of intracranial bleeding.

💉t-PA works by dissolving clots but can also increase bleeding risk, especially in those with previous brain bleeds.

🛑Administering thrombolytics in such patients may lead to fatal hemorrhagic complications.

📋Careful screening for contraindications is critical before initiating fibrinolytic therapy.

📌Core Message

A previous cerebral hemorrhage is an absolute contraindication to using t-PA due to the risk of intracranial bleeding.

Answer 4

Correct Answers:

Prevents DVT (deep vein thrombosis)

Rationale :

🦵Early ambulation and leg exercises after a myocardial infarction help reduce the risk of deep vein thrombosis due to immobility.

🩸Venous stasis from prolonged bed rest can lead to clot formation, especially in the lower limbs.

🛌Preventing DVT is critical since a clot can dislodge and cause pulmonary embolism, a potentially fatal complication.

🏥This intervention is part of standard post-MI care to minimize circulatory complications during recovery.

📌Core Message

Post-MI ambulation and leg exercises aim to prevent DVT, reducing the risk of serious thromboembolic events.

Answer 5

Correct Answers:

Confusion

Rationale :

🧠Confusion is a typical symptom of cardiogenic shock, resulting from inadequate cerebral perfusion.

❤️The failing heart is unable to pump enough blood to vital organs, causing hypoxia and mental status changes.

📉This state is characterized by low blood pressure, weak pulses, and decreased tissue perfusion, not bounding pulses.

🚨Prompt recognition and management of altered mental status can help prevent further hemodynamic deterioration.

📌Core Message

Cardiogenic shock leads to poor cerebral perfusion, often resulting in confusion and other mental status changes.

Answer 6

Correct Answers:

Check blood pressure.

Rationale :

🩺Checking vital signs, including blood pressure, is a priority in patients presenting with dyspnea to assess hemodynamic stability.

📊This quick, non-invasive intervention helps guide further evaluation and decisions, especially in patients with cardiac history.

🔍Without knowing the current cardiovascular status, other steps such as ABG or imaging might be inappropriate or delayed.

🚑Monitoring blood pressure first ensures prompt recognition of instability requiring urgent care.

📌Core Message

The first step for dyspnea in CHF is assessing blood pressure to determine hemodynamic status.

Answer 7

Correct Answers:

"Headaches are a frequent side effect of nitroglycerine because it causes vasodilation."

Rationale :

💥Nitroglycerin induces vasodilation, especially in cerebral vessels, which can result in headaches.

🧠This is a well-known side effect and usually diminishes with continued use or dose adjustment.

💊The nurse should reassure the patient while also recommending strategies to minimize discomfort, such as taking it with rest.

📚Educating patients on expected side effects helps improve medication adherence and reduce anxiety.

📌Core Message

Nitroglycerin frequently causes headaches due to its vasodilatory effects, especially in cerebral vessels.

Answer 8

Correct Answers:

The symptoms may be the result of anemia caused by chemotherapy.

Rationale :

🩸Chemotherapy often suppresses bone marrow function, leading to anemia, which causes fatigue and cognitive difficulty.

😴These symptoms are common in post-treatment patients and can persist even after cancer remission.

🧪Monitoring hemoglobin levels helps confirm whether anemia is the underlying cause.

🩹Supportive care may include iron supplementation, erythropoietin, or blood transfusion as appropriate.

📌Core Message

Post-chemotherapy anemia is a common cause of fatigue and cognitive difficulties in cancer survivors.

Answer 9

Correct Answers:

The patient should use iron cookware to prepare foods, such as dark-green, leafy vegetables, and legumes, which are high in iron.

Rationale :

🥬Vegetarian diets can be rich in non-heme iron, especially from legumes, leafy greens, and fortified grains.

🍳Cooking with iron cookware can enhance the iron content of meals by increasing iron absorption.

💡This approach supports hemoglobin improvement without needing to abandon vegetarianism.

🚫Adding coffee or tea can impair iron absorption due to tannins, and meat isn’t essential if plant iron is optimized.

📌Core Message

Vegetarians can improve iron intake through plant-based sources and iron cookware, supporting healthy hemoglobin levels.

Answer 10

Correct Answers:

A nurse should remain in the room during the first 15 minutes of infusion.

Rationale :

💁‍♂️The first 15 minutes of a blood transfusion are the most critical for observing transfusion reactions.

🚨Reactions such as fever, chills, or anaphylaxis often occur early and require immediate intervention.

🩸Staying with the patient ensures timely recognition and management of adverse events.

🧴Also, normal saline, not dextrose, should be used for flushing because dextrose can cause hemolysis.

📌Core Message

Transfusion reactions typically occur in the first 15 minutes, requiring continuous nursing presence during this time.

NCLEX PN-Readiness Assessment Test-4

No.

1 :
Which symptom listed below would not typically be observed following the administration of IV furosemide to a patient with congestive heart failure?

2 :
Among the listed factors associated with coronary artery disease, which one can be changed or controlled by the individual?

3 :
Which of the listed conditions would prevent the use of tissue plasminogen activator (t-PA) in a patient being treated for myocardial infarction?

4 :
Why is a patient who recently experienced a myocardial infarction encouraged to do leg exercises and ambulate in the hospital?

5 :
A patient with an evolving myocardial infarction progresses into cardiogenic shock. What symptom would most likely be observed?

6 :
What is the nurse’s immediate action when a patient with congestive heart failure reports difficulty breathing at a clinic visit?

7 :
A client prescribed nitroglycerin calls the clinic to report frequent headaches. What is the nurse’s best explanation for this symptom?

8 :
A colon cancer survivor in remission reports post-activity fatigue and trouble concentrating. What is the likely explanation for these symptoms?

9 :
What dietary recommendation is appropriate for a vegetarian patient with a hemoglobin of 10.8 g/dL?

10 :
What is the most critical nursing action when administering packed red blood cells (PRBCs) for severe anemia?

NCLEX PN-Readiness Assessment Test-4

No.

1 : Which symptom listed below would not typically be observed following the administration of IV furosemide to a patient with congestive heart failure?

2 : Among the listed factors associated with coronary artery disease, which one can be changed or controlled by the individual?

3 : Which of the listed conditions would prevent the use of tissue plasminogen activator (t-PA) in a patient being treated for myocardial infarction?

4 : Why is a patient who recently experienced a myocardial infarction encouraged to do leg exercises and ambulate in the hospital?

5 : A patient with an evolving myocardial infarction progresses into cardiogenic shock. What symptom would most likely be observed?

6 : What is the nurse’s immediate action when a patient with congestive heart failure reports difficulty breathing at a clinic visit?

7 : A client prescribed nitroglycerin calls the clinic to report frequent headaches. What is the nurse’s best explanation for this symptom?

8 : A colon cancer survivor in remission reports post-activity fatigue and trouble concentrating. What is the likely explanation for these symptoms?

9 : What dietary recommendation is appropriate for a vegetarian patient with a hemoglobin of 10.8 g/dL?

10 : What is the most critical nursing action when administering packed red blood cells (PRBCs) for severe anemia?

1 :
Which symptom listed below would not typically be observed following the administration of IV furosemide to a patient with congestive heart failure?

2 :
Among the listed factors associated with coronary artery disease, which one can be changed or controlled by the individual?

3 :
Which of the listed conditions would prevent the use of tissue plasminogen activator (t-PA) in a patient being treated for myocardial infarction?

4 :
Why is a patient who recently experienced a myocardial infarction encouraged to do leg exercises and ambulate in the hospital?

5 :
A patient with an evolving myocardial infarction progresses into cardiogenic shock. What symptom would most likely be observed?

6 :
What is the nurse’s immediate action when a patient with congestive heart failure reports difficulty breathing at a clinic visit?

7 :
A client prescribed nitroglycerin calls the clinic to report frequent headaches. What is the nurse’s best explanation for this symptom?

8 :
A colon cancer survivor in remission reports post-activity fatigue and trouble concentrating. What is the likely explanation for these symptoms?

9 :
What dietary recommendation is appropriate for a vegetarian patient with a hemoglobin of 10.8 g/dL?

10 :
What is the most critical nursing action when administering packed red blood cells (PRBCs) for severe anemia?