ATI RN
Physical Exam Cardiovascular System
1. The nurse is administering a beta blocker to a client with a heart rate of 58 bpm. What is the nurse’s priority action?
- A. Administer the beta blocker as ordered.
- B. Hold the beta blocker and notify the healthcare provider.
- C. Increase the dose of the beta blocker.
- D. Monitor the client’s heart rate and reassess in 30 minutes.
Correct answer: B
Rationale: The correct answer is B. A heart rate of 58 bpm is considered low, and beta blockers can further decrease the heart rate. Therefore, the nurse's priority action should be to hold the beta blocker and notify the healthcare provider for further assessment. Choice A is incorrect because administering the beta blocker without considering the low heart rate can worsen the condition. Choice C is incorrect as increasing the dose of the beta blocker can lead to further slowing of the heart rate, which is not safe in this situation. Choice D is not the priority action; holding the medication and seeking guidance from the healthcare provider is more crucial.
2. Which valve prevents backflow of blood into the right ventricle from the pulmonary artery?
- A. Pulmonary valve
- B. Aortic valve
- C. Tricuspid valve
- D. Mitral valve
Correct answer: A
Rationale: The correct answer is the Pulmonary valve. The Pulmonary valve prevents backflow of blood into the right ventricle from the pulmonary artery after it has been ejected. The Aortic valve (choice B) prevents backflow from the aorta into the left ventricle. The Tricuspid valve (choice C) prevents backflow of blood into the right atrium from the right ventricle. The Mitral valve (choice D) prevents backflow from the left ventricle into the left atrium.
3. What structures hold up the AV valves and are anchored to the ventricular wall by the papillary muscles?
- A. Chordae tendineae
- B. Papillary muscles
- C. Semilunar valves
- D. Aortic valve
Correct answer: A
Rationale: The correct answer is A: Chordae tendineae. Chordae tendineae are fibrous cords that connect the AV valves to the papillary muscles, preventing the valves from inverting during ventricular contraction. Papillary muscles (choice B) anchor the chordae tendineae to the ventricular wall but do not hold up the AV valves directly. Semilunar valves (choice C) are located between the ventricles and the major arteries and are not involved in holding up the AV valves. The aortic valve (choice D) is one of the semilunar valves and is not responsible for holding up the AV valves.
4. The nurse is caring for a client on warfarin with an INR of 5.2. What is the most appropriate action?
- A. Administer vitamin K as an antidote.
- B. Hold the next dose of warfarin.
- C. Increase the dose of warfarin.
- D. Monitor the client’s INR closely.
Correct answer: A
Rationale: An INR of 5.2 is elevated, indicating an increased risk of bleeding. Administering vitamin K can help reverse the effects of warfarin, which is the most appropriate action in this situation. Holding the next dose of warfarin is not enough to address the high INR, and increasing the dose would further elevate the INR level. Monitoring the INR closely is important, but in this case, immediate action is needed to counteract the anticoagulant effects of warfarin.
5. What is a condition where the heart's valves do not function properly, leading to disrupted blood flow within the heart?
- A. Valvular heart disease
- B. Myocarditis
- C. Endocarditis
- D. Aneurysm
Correct answer: A
Rationale: Valvular heart disease is the correct answer. It occurs when the heart's valves malfunction, leading to disrupted blood flow within the heart. Myocarditis refers to inflammation of the heart muscle, not specifically related to valve function. Endocarditis is an infection of the inner lining of the heart chambers and valves, not necessarily caused by valve malfunction. Aneurysm is the abnormal bulging of a blood vessel, not directly related to heart valve function.
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