ATI RN
Physical Exam Cardiovascular System
1. The client is on digoxin and has severe digoxin toxicity. What is the nursing priority action?
- A. Check the potassium level.
- B. Give Digibind as an antidote.
- C. Change the dosing of digoxin to every other day.
- D. Administer a potassium supplement to decrease digoxin toxicity.
Correct answer: B
Rationale: The correct answer is to give Digibind as an antidote in cases of severe digoxin toxicity. Digibind works by binding to digoxin and preventing it from causing further harm. Checking the potassium level (choice A) is important but not the priority when the client has severe toxicity. Changing the dosing to every other day (choice C) is not appropriate in the setting of severe toxicity where immediate action is required. Giving a potassium supplement (choice D) may be needed eventually, but the priority is to administer Digibind to counteract the toxic effects of digoxin.
2. What is a condition where the pulmonary arteries become blocked by a blood clot, leading to chest pain, shortness of breath, and other symptoms?
- A. Pulmonary embolism
- B. Pneumothorax
- C. Pulmonary edema
- D. Pulmonary hypertension
Correct answer: A
Rationale: The correct answer is A, pulmonary embolism. Pulmonary embolism is a condition where a blood clot blocks one of the pulmonary arteries in the lungs, resulting in symptoms like chest pain, shortness of breath, and other related signs. Choices B, C, and D are incorrect because pneumothorax refers to a collapsed lung, pulmonary edema is the build-up of fluid in the lungs, and pulmonary hypertension is high blood pressure in the arteries of the lungs - none of which directly involve a blood clot blocking the pulmonary arteries.
3. The nurse is caring for a client on amiodarone who complains of visual disturbances. What is the nurse’s best response?
- A. Notify the healthcare provider immediately.
- B. Reassure the client that this is a common side effect.
- C. Advise the client to monitor their symptoms at home.
- D. Suggest the client reduce physical activity.
Correct answer: A
Rationale: The correct answer is to notify the healthcare provider immediately. Visual disturbances in a client taking amiodarone can indicate amiodarone toxicity, a serious side effect. Notifying the healthcare provider promptly is essential for further assessment and management. Reassuring the client that this is a common side effect (choice B) is incorrect as visual disturbances should not be dismissed without evaluation. Advising the client to monitor their symptoms at home (choice C) may delay necessary intervention. Suggesting the client reduce physical activity (choice D) is unrelated to addressing visual disturbances caused by amiodarone.
4. What is a condition where blood clots form in the deep veins, usually in the legs, and can travel to the lungs, causing serious complications?
- A. Deep vein thrombosis (DVT)
- B. Pulmonary embolism
- C. Varicose veins
- D. Peripheral artery disease
Correct answer: A
Rationale: The correct answer is A, Deep vein thrombosis (DVT). Deep vein thrombosis occurs when blood clots form in the deep veins, usually in the legs, and these clots can potentially travel to the lungs, leading to a pulmonary embolism. Pulmonary embolism (choice B) is a serious complication that can result from untreated DVT. Varicose veins (choice C) and peripheral artery disease (choice D) are not directly related to the formation of blood clots in deep veins that can lead to pulmonary embolism.
5. What is the term used to describe a condition where the blood flow to the brain is temporarily interrupted, often referred to as a 'mini-stroke'?
- A. Transient ischemic attack (TIA)
- B. Stroke
- C. Myocardial infarction
- D. Pulmonary embolism
Correct answer: A
Rationale: The correct answer is A: Transient ischemic attack (TIA). A transient ischemic attack (TIA) is often called a 'mini-stroke' because it is characterized by a temporary interruption of blood flow to the brain, resulting in stroke-like symptoms that typically resolve within a short period. Choice B, 'Stroke,' is incorrect because a stroke involves a more prolonged interruption of blood flow, leading to lasting brain damage. Choices C and D, 'Myocardial infarction' and 'Pulmonary embolism,' are unrelated conditions involving the heart and lungs, respectively, and do not describe a temporary interruption of blood flow to the brain.
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