ATI RN
Cardiovascular System Practice Exam
1. The client is on spironolactone (Aldactone) and has a potassium level of 5.9 mEq/L. What is the nurse’s priority action?
- A. Hold the spironolactone and notify the healthcare provider.
- B. Administer potassium supplements.
- C. Continue the spironolactone as ordered.
- D. Increase the dose of spironolactone.
Correct answer: A
Rationale: The correct answer is A: Hold the spironolactone and notify the healthcare provider. A potassium level of 5.9 mEq/L is high, indicating hyperkalemia. Spironolactone is a potassium-sparing diuretic that can further increase potassium levels. Therefore, the priority action is to hold the medication to prevent exacerbating hyperkalemia and notify the healthcare provider for further guidance. Choice B is incorrect because administering potassium supplements would worsen hyperkalemia. Choice C is incorrect because continuing spironolactone could lead to a further increase in potassium levels. Choice D is incorrect because increasing the dose of spironolactone would exacerbate the hyperkalemia.
2. What procedure is most appropriate for the assessment of an abdominal circumference related to a bowel obstruction?
- A. Measuring the abdomen after feedings
- B. Marking the point of measurement with a pen
- C. Measuring the circumference at the symphysis pubis
- D. Using a new tape measure with each assessment to ensure accuracy
Correct answer: B
Rationale: Marking the point of measurement ensures consistent and accurate assessments of abdominal circumference, especially important in conditions like bowel obstruction where changes need to be monitored closely.
3. A client is postoperative, and a nurse is developing a plan of care. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?
- A. Perform range-of-motion exercises
- B. Place suction equipment at the bedside
- C. Encourage the use of an incentive spirometer
- D. Administer an expectorant
Correct answer: Encourage the use of an incentive spirometer
Rationale: Encouraging the use of an incentive spirometer is vital in preventing pulmonary complications postoperatively. The incentive spirometer helps the client perform deep breathing exercises, promoting lung expansion, and preventing atelectasis. Range-of-motion exercises help prevent musculoskeletal complications, while placing suction equipment at the bedside is important but not directly related to preventing pulmonary complications. Administering an expectorant may help with clearing secretions but is not as effective in preventing postoperative pulmonary complications as using an incentive spirometer.
4. What type of debridement involves proteolytic enzymes?
- A. Interventional C. Surgical
- B. Mechanical D. Chemical
- C.
- D.
Correct answer: B
Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.
5. A client with OCD has a new prescription for Paroxetine. Which of the following instructions should the nurse include?
- A. It can take several weeks before you feel like the medication is helping.
- B. Take the medication just before bedtime to promote sleep.
- C. You should take the medication when needed for obsessive urges.
- D. Monitor for weight gain while taking this medication.
Correct answer: A
Rationale: The correct answer is A. Paroxetine, an antidepressant commonly used for OCD, typically takes 1 to 4 weeks before the client experiences the full therapeutic benefit. Therefore, informing the client that it may take several weeks before feeling the medication's effects is crucial to manage expectations and ensure compliance with the treatment plan. Choice B is incorrect because Paroxetine is usually taken in the morning due to its activating effects and may cause insomnia if taken before bedtime. Choice C is incorrect because Paroxetine should be taken regularly as prescribed, not just when experiencing obsessive urges. Choice D is incorrect because although weight gain can be a side effect of Paroxetine, it is not a priority instruction compared to the delayed onset of therapeutic effects.
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