ATI RN
Cardiovascular System Exam
1. The client on a beta blocker has a blood pressure of 88/58 mm Hg. What is the nurse’s priority action?
- A. Hold the beta blocker and notify the healthcare provider.
- B. Administer the beta blocker as ordered.
- C. Increase the dose of the beta blocker.
- D. Continue to monitor the client and reassess in 30 minutes.
Correct answer: A
Rationale: The correct action for the nurse to take when a client on a beta blocker presents with a blood pressure of 88/58 mm Hg is to hold the beta blocker and notify the healthcare provider. Beta blockers can further decrease blood pressure, which is already low in this case. Administering the beta blocker as ordered (Choice B) would exacerbate the hypotension. Increasing the dose of the beta blocker (Choice C) would be inappropriate and unsafe given the low blood pressure. Continuing to monitor the client and reassessing in 30 minutes (Choice D) could lead to a delay in necessary intervention. Therefore, the priority is to hold the medication and seek guidance from the healthcare provider.
2. The client is receiving digoxin and complains of nausea. What is the nurse’s priority action?
- A. Check the client’s digoxin level.
- B. Continue the current dose of digoxin.
- C. Administer an antiemetic for nausea.
- D. Discontinue the digoxin immediately.
Correct answer: A
Rationale: The correct answer is to check the client’s digoxin level (Choice A). Nausea can be a sign of digoxin toxicity, so assessing the digoxin level is crucial to determine if the medication dosage needs adjustment. Continuing the current dose of digoxin (Choice B) may worsen the symptoms if toxicity is present. Administering an antiemetic (Choice C) may provide temporary relief but does not address the underlying issue of digoxin toxicity. Discontinuing digoxin immediately (Choice D) without assessing the digoxin level can be harmful if the medication is within the therapeutic range.
3. Which term refers to a condition where the blood supply to part of the heart muscle is blocked, often referred to as a heart attack?
- A. Myocardial infarction
- B. Arrhythmia
- C. Stroke
- D. Aneurysm
Correct answer: A
Rationale: The correct answer is A, myocardial infarction. A myocardial infarction, commonly known as a heart attack, occurs when the blood supply to part of the heart muscle is blocked, often by a blood clot. Choices B, C, and D are incorrect because arrhythmia refers to an irregular heartbeat, stroke involves the interruption of blood flow to the brain, and an aneurysm is a bulge in a blood vessel.
4. The client is on furosemide (Lasix) and has a potassium level of 2.9 mEq/L. What is the nurse’s priority action?
- A. Administer potassium supplements.
- B. Hold the furosemide and notify the healthcare provider.
- C. Continue the current dose of furosemide.
- D. Decrease the dose of furosemide.
Correct answer: A
Rationale: The correct answer is A: Administer potassium supplements. A potassium level of 2.9 mEq/L indicates hypokalemia (low potassium levels). Furosemide (Lasix) is a loop diuretic that can cause potassium loss. Therefore, the priority action is to administer potassium supplements to correct the imbalance. Option B is incorrect because holding the furosemide without addressing the low potassium level could further worsen the imbalance. Option C is incorrect as continuing the current dose of furosemide without addressing the low potassium level could lead to complications. Option D is incorrect because decreasing the dose of furosemide does not directly address the low potassium level that needs immediate correction.
5. What condition is characterized by the inflammation of the pleura, causing sharp chest pain that worsens with breathing?
- A. Pleurisy
- B. Pericarditis
- C. Endocarditis
- D. Myocarditis
Correct answer: A
Rationale: The correct answer is Pleurisy. Pleurisy is the inflammation of the pleura, the lining surrounding the lungs, which causes sharp chest pain that worsens with breathing. Pericarditis (choice B) is the inflammation of the pericardium, the sac around the heart, which typically causes chest pain that worsens when lying down. Endocarditis (choice C) is the inflammation of the inner lining of the heart chambers and valves, leading to symptoms like fever, fatigue, and abnormal heart sounds. Myocarditis (choice D) is inflammation of the heart muscle, which can cause symptoms such as chest pain, fatigue, and shortness of breath.
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