ATI RN
Cardiovascular System Exam
1. The client is on a beta blocker for hypertension. What should the nurse monitor for?
- A. Bradycardia
- B. Tachycardia
- C. Hypertension
- D. Respiratory distress
Correct answer: A
Rationale: Corrected Rationale: When a client is on a beta blocker for hypertension, the nurse should monitor for bradycardia. Beta blockers are known to decrease heart rate, which can lead to bradycardia. Tachycardia (choice B) is unlikely as beta blockers have the opposite effect. Hypertension (choice C) is the condition being treated, not a side effect of beta blockers. Respiratory distress (choice D) is not a common effect of beta blockers and is not typically monitored in clients taking beta blockers.
2. A client with deep vein thrombosis (DVT) is receiving heparin therapy. What is the priority assessment for the nurse?
- A. Monitoring blood pressure
- B. Checking the activated partial thromboplastin time (aPTT)
- C. Assessing for signs of bleeding
- D. Measuring calf circumference
Correct answer: C
Rationale: Assessing for signs of bleeding is the priority when caring for a client with deep vein thrombosis (DVT) receiving heparin therapy. Heparin therapy increases the risk of bleeding complications, so monitoring for signs of bleeding is crucial to ensure patient safety and timely intervention if needed.
3. An infant, age 6 months, has six teeth. The nurse should recognize that this is what?
- A. Normal tooth eruption
- B. Delayed tooth eruption
- C. Unusual and dangerous
- D. Earlier than expected tooth eruption
Correct answer: D
Rationale: Having six teeth at 6 months is earlier than the typical tooth eruption schedule, but it is not unusual or dangerous. It is within the range of normal variations in infant development.
4. As a result of opioid administration, a child's respirations are slow and shallow. Which should the nurse anticipate when assessing the child's arterial blood gas?
- A. Increased PCO2 and respiratory acidosis
- B. Decreased PCO2 and respiratory alkalosis
- C. Low pH and low PCO2
- D. High pH and high PCO2
Correct answer: A
Rationale: When a child's respirations are slow and shallow due to opioid administration, it results in hypoventilation. This leads to retaining carbon dioxide, indicated by an increased PCO2 level on arterial blood gas analysis, and subsequently causes respiratory acidosis due to the buildup of CO2 in the blood. Therefore, choice A, 'Increased PCO2 and respiratory acidosis,' is the correct answer. Choices B, C, and D are incorrect because slow and shallow respirations would not lead to decreased PCO2 or respiratory alkalosis (choice B), low pH and low PCO2 (choice C), or high pH and high PCO2 (choice D).
5. A client has a new prescription for Hydralazine. Which of the following adverse effects should the nurse instruct the client to monitor?
- A. Tachycardia
- B. Hyperglycemia
- C. Hyponatremia
- D. Constipation
Correct answer: A
Rationale: Corrected Rationale: Hydralazine is a vasodilator that can cause reflex tachycardia as an adverse effect. The client should monitor their pulse and report any significant increases, as tachycardia can indicate a severe adverse reaction to the medication. Choice B, Hyperglycemia, is not a common adverse effect of Hydralazine. Choice C, Hyponatremia, and Choice D, Constipation, are also not typically associated with Hydralazine use. Therefore, the correct answer is A: Tachycardia.
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