NCLEX practice questions: heart failure

Heart failure questions test fluid overload signs, daily weights, sodium and fluid limits, and the drugs that need monitoring like diuretics and digoxin.

1. Question 1

   A client with heart failure has been admitted three times in 6 months. The nurse is preparing the client for discharge. Which action is most likely to prevent another readmission?

   • A.Give the client a printed pamphlet about heart failure
   • B.Schedule a follow-up appointment within 7 days before the client leaves
   • C.Tell the client to call the provider if any problems occur
   • D.Advise the client to see the primary care provider sometime in the next few months
   Show answer and explanation

   Answer: B

   The early weeks after discharge carry a high readmission risk. An early scheduled visit, often recommended within about 7 to 14 days for heart failure depending on the client's needs, along with teach-back on daily weights, symptoms and medications, is a key transitional care strategy.

   • A. Written material alone, without teach-back or follow-up, has little effect on readmissions.
   • B. Correct. Early follow-up after discharge finds problems such as fluid gain or medication issues before they become emergencies.
   • C. This is vague and depends on the client recognizing problems without clear guidance.
   • D. This is too late. Readmission risk is high in the first weeks after discharge.

   Key concept: Early, scheduled follow-up is a core strategy to prevent readmission after discharge.

   Tip: Leave with a date: book the follow-up before they walk out.

2. Question 2

   A client admitted with heart failure and fluid overload received furosemide 40 mg IV twice yesterday. Which finding best shows that the medication is having the desired effect?

   • A.Weight down 3.3 lb (1.5 kg) since yesterday and fewer crackles in the lungs
   • B.Serum potassium of 3.4 mEq/L
   • C.Urine specific gravity of 1.030
   • D.Blood pressure dropped from 128/76 to 100/58 mmHg
   Show answer and explanation

   Answer: A

   Furosemide is a loop diuretic that removes sodium and water. In heart failure, effectiveness is shown by daily weight loss, better breath sounds, less edema and easier breathing. Daily weight is the most reliable measure of fluid balance; 1 kg is about 1 liter of fluid.

   • A. Correct. Weight loss and clearer lungs show that excess fluid is being removed, which is the goal of diuretic therapy in heart failure.
   • B. Low potassium is an adverse effect of furosemide, not a sign that the drug is working.
   • C. A high specific gravity shows concentrated urine, which suggests little diuresis or dehydration, not effective fluid removal.
   • D. Some drop in blood pressure can happen, but hypotension is an adverse effect to watch for. It does not show that fluid overload has improved.

   Key concept: Evaluate diuretics by fluid outcomes: daily weight, lung sounds, edema and urine output.

   Tip: 1 kg lost = about 1 L of fluid off.

3. Question 3

   Six hours after surgery, a client with a history of heart failure has a blood pressure of 82/54 mmHg and a heart rate of 120/min. Which finding most strongly suggests the cause is cardiogenic rather than hypovolemic?

   • A.Fast, thready pulse
   • B.Distended neck veins and crackles in both lungs
   • C.Cool, pale, clammy skin over the arms, legs and trunk
   • D.Urine output of 15 mL/hr
   Show answer and explanation

   Answer: B

   Hypovolemic and cardiogenic shock both cause hypotension, tachycardia, cool skin and low urine output. The key difference is volume status: hypovolemic shock has flat neck veins and clear lungs, while cardiogenic shock has distended neck veins, crackles and high filling pressures. This difference guides treatment: fluids for hypovolemia, but inotropes and careful fluid management for cardiogenic shock.

   • A. A fast, weak pulse occurs in both types of shock.
   • B. These show that blood is backing up because the heart cannot pump it forward, which points to pump failure.
   • C. Cool, pale skin occurs in both cardiogenic and hypovolemic shock because of vasoconstriction.
   • D. Low urine output occurs in all types of shock.

   Key concept: Shock with distended neck veins and crackles = think pump failure, not low volume.

   Tip: 'Wet and cold' = cardiogenic; 'dry and cold' = hypovolemic.

4. Question 4

   A client comes to the emergency department with shortness of breath and leg swelling. The B-type natriuretic peptide (BNP) is 1,250 pg/mL (reference less than 100 pg/mL). Which condition does this result most strongly support?

   • A.Asthma
   • B.Pneumonia
   • C.Iron deficiency anemia
   • D.Heart failure
   Show answer and explanation

   Answer: D

   The ventricles release BNP when they are stretched. In a client with shortness of breath and leg swelling, a level this high supports heart failure. BNP is not specific on its own: age, kidney disease and other conditions also raise it, so it is read together with the history, exam and imaging. It also helps track the response to treatment.

   • A. Asthma causes shortness of breath, but it does not raise BNP to this level.
   • B. Pneumonia may raise BNP slightly, but a very high level points to a heart cause.
   • C. Anemia causes fatigue and shortness of breath but does not cause a BNP this high.
   • D. Correct. BNP is released when the ventricles are stretched by too much volume or pressure. A very high level strongly supports heart failure.

   Key concept: BNP rises with ventricular stretch; it is a key marker for heart failure.

   Tip: B-type = Big, stretched heart.

5. Question 5

   A client in the cardiac ICU has a pulmonary artery catheter. The pulmonary artery wedge pressure (PAWP) is 24 mmHg (normal 8 to 12) and the nurse hears crackles in both lungs. Which prescription should the nurse expect?

   • A.IV furosemide
   • B.Albumin 25% IV
   • C.0.9% sodium chloride bolus of 1,000 mL
   • D.Lower the head of the bed to flat
   Show answer and explanation

   Answer: A

   PAWP estimates left atrial pressure and left ventricular preload. A high value with crackles means the left ventricle cannot handle the volume and fluid is backing into the lungs. Treatment reduces preload with diuretics and vasodilators, and the client is positioned upright.

   • A. A high PAWP shows high left-sided filling pressure. Blood is backing up into the lungs, and a diuretic lowers preload.
   • B. Albumin pulls fluid into vessels and adds to volume, which would worsen congestion.
   • C. More fluid would raise the wedge pressure further and worsen pulmonary edema.
   • D. Lying flat increases venous return and breathlessness in pulmonary congestion.

   Key concept: High PAWP = left-sided congestion; low PAWP = low volume.

   Tip: PAWP is 'the left heart's fuel gauge.'