ATI RN
Physical Exam Cardiovascular System
1. The nurse is administering a beta blocker to a client with a heart rate of 50 bpm. What is the priority action?
- A. Hold the beta blocker and notify the healthcare provider.
- B. Administer the beta blocker as ordered.
- C. Decrease the dose of the beta blocker.
- D. Monitor the client’s heart rate and reassess in 30 minutes.
Correct answer: A
Rationale: The correct action is to hold the beta blocker and notify the healthcare provider. A heart rate of 50 bpm is already low, and beta blockers can further decrease the heart rate, potentially causing adverse effects like bradycardia or heart block. Administering the beta blocker as ordered (Choice B) can exacerbate the low heart rate. Decreasing the dose of the beta blocker (Choice C) may not be sufficient to address the potential harm. Monitoring the client’s heart rate and reassessing in 30 minutes (Choice D) may delay necessary interventions if the heart rate drops further. Therefore, the priority is to hold the medication and seek guidance from the healthcare provider.
2. The client on spironolactone should avoid which of the following?
- A. Foods high in potassium
- B. Foods high in sodium
- C. Foods high in calcium
- D. Foods high in chloride
Correct answer: A
Rationale: The correct answer is A: Foods high in potassium. Spironolactone is a potassium-sparing diuretic, meaning it helps the body retain potassium and excrete sodium. Consuming foods high in potassium while on spironolactone can lead to an excess of potassium in the body, potentially causing hyperkalemia. Choices B, C, and D are incorrect because spironolactone does not directly interact with sodium, calcium, or chloride in a way that would require specific dietary restrictions related to these minerals.
3. What is the abnormal accumulation of fluid in the pleural space, often associated with infections or malignancies?
- A. Pleural effusion
- B. Pneumothorax
- C. Pulmonary edema
- D. Atelectasis
Correct answer: A
Rationale: The correct answer is A, pleural effusion. Pleural effusion is the accumulation of excess fluid between the layers of the pleura outside the lungs, often caused by infections, cancer, or other diseases. Pneumothorax (choice B) is the presence of air in the pleural space, not fluid. Pulmonary edema (choice C) is the accumulation of fluid in the lungs' air sacs and tissue, not in the pleural space. Atelectasis (choice D) is the collapse or closure of a lung resulting in reduced or absent gas exchange.
4. This is a test that measures the oxygen saturation level in the blood, often used to assess respiratory function.
- A. Pulse oximetry
- B. Spirometry
- C. Arterial blood gas (ABG)
- D. Lung function test
Correct answer: A
Rationale: The correct answer is A, Pulse oximetry. Pulse oximetry is a non-invasive test that measures the oxygen saturation level in the blood, helping to assess respiratory and cardiovascular function. Choice B, Spirometry, measures lung function by assessing airflow and volume. Choice C, Arterial blood gas (ABG), evaluates the acidity, oxygen, and carbon dioxide levels in the blood. Choice D, Lung function test, is a broad term that may include various tests to assess lung health, but specifically measuring oxygen saturation is done through pulse oximetry.
5. Which of the following is a central vasodilator and peripheral vasoconstrictor?
- A. Sympathetic nervous system
- B. Parasympathetic nervous system
- C. Norepinephrine
- D. Acetylcholine
Correct answer: A
Rationale: The correct answer is the Sympathetic nervous system. The sympathetic nervous system is a branch of the autonomic nervous system that is responsible for the fight-or-flight response. It causes vasodilation in central vessels to increase blood flow to vital organs during stress or exercise, while inducing vasoconstriction in peripheral vessels to redirect blood to essential areas. Norepinephrine and acetylcholine are neurotransmitters associated with the sympathetic and parasympathetic nervous systems, respectively, but they are not themselves central vasodilators and peripheral vasoconstrictors.
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