ATI RN
Physical Exam Cardiovascular System
1. The nurse is administering digoxin to a client. What is the most important parameter to check before administration?
- A. Heart rate
- B. Blood pressure
- C. Respiratory rate
- D. Oxygen saturation
Correct answer: A
Rationale: The correct answer is A: Heart rate. Before administering digoxin, it is crucial to check the client's heart rate because digoxin can cause bradycardia, making it essential to ensure the heart rate is within the appropriate range. Blood pressure, respiratory rate, and oxygen saturation are also important parameters to monitor in a clinical setting, but when administering digoxin, the focus should primarily be on the heart rate due to its potential effects on cardiac function.
2. A nurse is caring for a client who is receiving chemotherapy treatments. The client states, 'I feel so nauseated after my treatments.' Which of the following instructions should the nurse provide the client?
- A. Common foods that are served cold.
- B. Sip fluids slowly throughout the day.
- C. Sit up for 1 hr after eating meals.
- D. All of the Above
Correct answer: D
Rationale: Common foods served cold, sitting up after meals, and sipping fluids slowly can help manage nausea associated with chemotherapy.
3. A client with heart failure has gained 2 kg (4.4 lbs) in the past 24 hours. What action should the nurse take first?
- A. Restrict the client's fluid intake.
- B. Assess the client's respiratory status.
- C. Administer diuretics as ordered.
- D. Notify the healthcare provider.
Correct answer: B
Rationale: Assessing the client's respiratory status is the priority as it helps determine if the weight gain is due to fluid retention affecting breathing. This assessment is crucial in addressing the immediate concern of potential respiratory distress before implementing interventions like fluid restriction, diuretics, or notifying the healthcare provider.
4. A client is to receive Tetracaine before a Bronchoscopy. Which of the following actions should the nurse include in the plan of care?
- A. Keep the client NPO until the pharyngeal response returns.
- B. Monitor the insertion site for a hematoma.
- C. Palpate the bladder to detect urinary retention.
- D. Maintain the client on bed rest for 12 hours following the procedure.
Correct answer: A
Rationale: The correct action for the nurse to include in the plan of care is to keep the client NPO until the pharyngeal response returns. Tetracaine can affect the gag reflex, so it is important to prevent aspiration by maintaining the client NPO until the pharyngeal response is normal, which typically takes about 1 hour. Monitoring for the return of the gag reflex is crucial to prevent complications from aspiration during the first oral intake after the procedure. Choices B, C, and D are incorrect because they are not directly related to the effects of Tetracaine or the bronchoscopy procedure.
5. A nurse is providing education to a patient starting hormone replacement therapy (HRT) for menopausal symptoms. What should the nurse emphasize regarding the long-term risks associated with HRT?
- A. HRT may increase the risk of cardiovascular events, including heart attack and stroke.
- B. HRT may decrease the risk of osteoporosis.
- C. HRT may improve mood and energy levels.
- D. HRT may decrease the risk of breast cancer.
Correct answer: A
Rationale: HRT is associated with an increased risk of cardiovascular events, including heart attack and stroke, particularly with long-term use.
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