ATI RN
Physical Exam Cardiovascular System
1. The client on spironolactone (Aldactone) has a potassium level of 5.6 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 5.6 mEq/L is high, indicating hyperkalemia. Spironolactone is a potassium-sparing diuretic that can further elevate potassium levels. Therefore, the priority action is to withhold the medication to prevent exacerbating hyperkalemia and notify the healthcare provider for further management. Option B is incorrect because administering potassium supplements would worsen the hyperkalemia. Option C is incorrect as continuing spironolactone can lead to a further increase in potassium levels. Option D is incorrect as increasing the dose of spironolactone would be inappropriate in the presence of elevated potassium levels.
2. A client with diabetes mellitus is receiving education from a nurse on preventing long-term complications. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will keep my blood glucose levels within the target range.
- B. I will check my feet daily for any open sores or wounds.
- C. I will monitor my blood pressure regularly.
- D. I will consume foods that are high in fiber.
Correct answer: B
Rationale: The correct answer is B: 'I will check my feet daily for any open sores or wounds.' This statement shows an understanding of the importance of foot care in preventing complications like diabetic foot ulcers. Monitoring blood glucose levels (choice A) is crucial but not directly related to foot care. Monitoring blood pressure (choice C) is important for overall health but does not specifically address preventing long-term complications of diabetes. Consuming foods high in fiber (choice D) is beneficial for managing blood sugar levels but does not directly address preventing foot complications.
3. You are on duty in the medical ward. The mother of your patient who is also a nurse, came running to the nurses station and informed you that Fiolo went into cardiopulmonary arrest.
- A. Start basic life support measures
- B. Call for the Code
- C. Bring the crash cart to the room
- D. Go to see Fiolo and assess for airway patency and breathing problems
Correct answer: C
Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.
4. Which dietary change is most beneficial for a patient with hypertension?
- A. Increased sodium intake
- B. Decreased potassium intake
- C. Increased fiber intake
- D. Increased cholesterol intake
Correct answer: C
Rationale: The correct answer is C: Increased fiber intake. A diet high in fiber is beneficial for patients with hypertension as it helps lower blood pressure. Increasing fiber intake can aid in managing hypertension by promoting heart health and overall well-being. Choices A, B, and D are incorrect. Increased sodium intake is not recommended for hypertension as it can elevate blood pressure. Decreasing potassium intake is also not advised as potassium is essential for regulating blood pressure. Lastly, increasing cholesterol intake is detrimental for hypertension as it can contribute to cardiovascular issues and worsen the condition.
5. Which of the following definitions best describes diverticulosis?
- A. An inflamed outpouching of the intestine
- B. A noninflamed outpouching of the intestine
- C. The partial impairment of the forward flow of intestinal contents
- D. An abnormal protrusion of an organ through the structure that usually holds it
Correct answer: B
Rationale: The correct answer is B: 'A noninflamed outpouching of the intestine.' Diverticulosis refers to the presence of small, bulging pouches (diverticula) that can form in the lining of the digestive system, especially the colon. These pouches are typically noninflamed. Choice A is incorrect because it describes diverticulitis, which is the inflammation of these pouches. Choice C is incorrect as it defines bowel obstruction, not diverticulosis. Choice D is incorrect as it refers to a hernia, not diverticulosis.
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