ATI RN
Cardiovascular System Exam
1. A client on spironolactone (Aldactone) has a potassium level of 6.0 mEq/L. What is the nurse’s priority action?
- A. Hold the spironolactone and notify the healthcare provider.
- B. Administer a potassium supplement.
- C. Continue the spironolactone as ordered.
- D. Increase the dose of spironolactone.
Correct answer: A
Rationale: The correct action for a client on spironolactone with a potassium level of 6.0 mEq/L is to hold the medication and notify the healthcare provider. Spironolactone is a potassium-sparing diuretic that can further elevate potassium levels, which are already high. Administering a potassium supplement (Choice B) would exacerbate the hyperkalemia. Continuing the spironolactone as ordered (Choice C) could lead to worsening hyperkalemia. Increasing the dose of spironolactone (Choice D) would be contraindicated in the presence of elevated potassium levels.
2. A nurse is caring for a newborn in the nursery following a circumcision. The newborn's grandparent, who does not have an identification bracelet, requests to take the newborn to his parents' room. Which of the following actions should the nurse take?
- A. Check the newborn's identification bracelet against the chart
- B. Obtain permission from the newborn's parents
- C. Respectfully deny the grandparent's request
- D. Review the newborn's footprints record
Correct answer: C
Rationale: In this scenario, where the grandparent lacks proper identification, the nurse should respectfully deny the request to take the newborn. It is crucial to prioritize the newborn's safety and security by following hospital policies and procedures. Checking the newborn's identification bracelet against the chart (Choice A) may not be sufficient to address the situation at hand, as the grandparent's lack of identification is the primary concern. While obtaining permission from the newborn's parents (Choice B) is important, the lack of proper identification from the grandparent takes precedence. Reviewing the newborn's footprints record (Choice D) is not necessary in this situation, as the immediate concern is ensuring proper identification and security before allowing the newborn to leave the nursery.
3. A homeless man was screened for tuberculosis (TB) during a health consultation at a shelter, and the results indicate latent TB. The community health nurse who is liaising with the providers of the shelter would anticipate what component of this man's plan of care?
- A. The man will undergo conservative treatment for TB using adjuvant medications.
- B. The man will be treated for TB using first-line antitubercular drugs.
- C. The man will be monitored closely to determine if treatment is necessary.
- D. The man will be screened again in 10 to 12 weeks to determine if he has developed active TB.
Correct answer: B
Rationale: The correct answer is B. When a patient is diagnosed with latent TB infection, the standard approach involves treating them with first-line antitubercular drugs to prevent the progression to active TB. Adjuvant medications are not typically used for latent TB. Close monitoring without initiating treatment can lead to the development of active TB, so immediate treatment is crucial. Screening the individual again in 10 to 12 weeks does not address the immediate need for treatment of latent TB, which is essential to prevent the progression of the disease.
4. Which term involves the voluntary fortification of processed foods?
- A. Garantisadong Pambata
- B. Food Fortification
- C. Sangkap Pinoy Seal
- D. Child Health Week
Correct answer: C
Rationale: The Sangkap Pinoy Seal signifies the voluntary fortification of processed foods in the Philippines. It serves as a mark that indicates the inclusion of essential nutrients in processed food products to address specific nutrient deficiencies in the population.
5. Sharon has cirrhosis of the liver and develops ascites. What intervention is necessary to decrease the excessive accumulation of serous fluid in her peritoneal cavity?
- A. Restrict fluids
- B. Encourage ambulation
- C. Increase sodium in the diet
- D. Give antacids as prescribed
Correct answer: A
Rationale: Restricting fluids is necessary to decrease the excessive accumulation of serous fluid in the peritoneal cavity for a patient with ascites due to cirrhosis.
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