ATI RN
Cardiovascular System Exam
1. The client is on amiodarone. What is the most important side effect to monitor for?
- A. Pulmonary toxicity
- B. Thyroid dysfunction
- C. Liver toxicity
- D. Renal dysfunction
Correct answer: A
Rationale: The correct answer is A: Pulmonary toxicity. Amiodarone is known for causing serious pulmonary toxicity, which can be fatal. Monitoring for pulmonary toxicity is crucial due to its potential severity. Choice B, thyroid dysfunction, is a common side effect of amiodarone but is not as immediately life-threatening as pulmonary toxicity. Choices C and D, liver toxicity and renal dysfunction, are potential side effects of amiodarone but are not as critical or as common as pulmonary toxicity, making them less important to monitor initially.
2. Before administering blood products, which action should be taken?
- A. Assess the client's temperature
- B. Document client response
- C. Prime IV tubing with 0.45% sodium chloride
- D. Administer epinephrine
Correct answer: A
Rationale: Correct answer: Before administering blood products, the client's temperature must be assessed to establish a baseline and monitor for transfusion reactions. Choice B is incorrect because documenting client response should occur after administering the blood products. Choice C is incorrect as priming IV tubing with 0.45% sodium chloride is not directly related to assessing the client before administering blood products. Choice D is incorrect because administering epinephrine is not a routine action before administering blood products.
3. Crohn’s disease can be described as a chronic relapsing disease. Which of the following areas in the GI system may be involved with this disease?
- A. The entire length of the large colon
- B. Only the sigmoid area
- C. The entire large colon through the layers of mucosa and submucosa
- D. The small intestine and colon; affecting the entire thickness of the bowel
Correct answer: D
Rationale: Crohn's disease can affect any part of the gastrointestinal tract from the mouth to the anus, but it commonly affects the small intestine and colon, involving the entire thickness of the bowel wall.
4. A nurse is assessing a client who is 48 hours postoperative following a hip replacement. Which of the following findings should the nurse report to the provider?
- A. Heart rate 90/min.
- B. WBC count 15,000/mm3.
- C. Urinary output 75 mL in the past 4 hours.
- D. Temperature 37.8°C (100°F).
Correct answer: B
Rationale: An elevated WBC count 48 hours postoperatively may indicate an infection and should be reported to the provider. Choice A, a heart rate of 90/min, is within normal limits and not a concerning finding postoperatively. Choice C, urinary output of 75 mL in the past 4 hours, may indicate decreased renal perfusion, but an elevated WBC count is a more urgent finding. Choice D, a temperature of 37.8°C (100°F), which is slightly elevated, could be indicative of the body's normal response to surgery and is not as alarming as an elevated WBC count.
5. What is the most appropriate nursing diagnosis for the client's son based on the information provided?
- A. Risk for other-directed violence
- B. Disturbed sleep pattern
- C. Caregiver role strain
- D. Social isolation
Correct answer: C
Rationale: The correct answer is 'Caregiver role strain.' In the scenario presented, the son expresses that his father's constant confusion, incontinence, and tendency to wander are intolerable. These challenges indicate that the son is experiencing strain in his role as a caregiver. 'Risk for other-directed violence' is not appropriate because there is no indication of violent behavior. 'Disturbed sleep pattern' is not the most relevant nursing diagnosis given the information provided. 'Social isolation' is not the most appropriate choice as the son's concerns are related to the challenges of caregiving, not isolation.
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