ATI RN
Cardiovascular System Exam Questions
1. The nurse is caring for a client on heparin. What is the most important lab value to monitor?
- A. aPTT
- B. INR
- C. Platelet count
- D. Hemoglobin
Correct answer: A
Rationale: The correct answer is A: aPTT. When a client is on heparin therapy, monitoring the aPTT is crucial. The aPTT helps assess the effectiveness of heparin in preventing blood clots and guides dose adjustments as needed. INR (Choice B) is more commonly used to monitor warfarin therapy. Platelet count (Choice C) is important to assess for potential bleeding disorders or thrombocytopenia but is not the primary lab value to monitor for heparin therapy. Hemoglobin (Choice D) is essential for assessing oxygen-carrying capacity but is not the most important lab value to monitor when a client is on heparin.
2. A patient is receiving radiation therapy. Which of the following skin care instructions should the nurse provide?
- A. Apply a heating pad to the radiation site.
- B. Use scented lotions to moisturize the skin.
- C. Keep the radiation site covered with a bandage.
- D. Wear loose clothing over the radiation site.
Correct answer: D
Rationale: Correct Answer: The nurse should instruct the patient to wear loose clothing over the radiation site. This helps prevent skin irritation and promotes healing by reducing friction and irritation on the treated area.\nChoice A is incorrect because applying a heating pad can further irritate the skin that is already sensitive due to radiation therapy.\nChoice B is incorrect because scented lotions may contain ingredients that could further irritate the skin.\nChoice C is incorrect because covering the radiation site with a bandage can trap moisture and lead to skin breakdown, increasing the risk of infection.
3. A client has global aphasia affecting both receptive and expressive language abilities. Which intervention should NOT be included in the client's care plan?
- A. Speak to the client at a slower rate.
- B. Assist the client in using flash cards with pictures.
- C. Speak to the client in a loud voice.
- D. Give instructions one step at a time.
Correct answer: C: Speak to the client in a loud voice.
Rationale: Individuals with global aphasia have difficulty understanding and expressing language. Speaking loudly may not improve comprehension and can be perceived as aggressive. Therefore, it is important not to speak loudly to a client with global aphasia. Speaking at a slower rate, using visual aids like flash cards, and breaking down instructions into simple steps can facilitate communication and understanding for the client.
4. Interacting with the patient and their family to obtain subjective information is part of which of the following steps in determining and fulfilling the nursing care needs of the patient?
- A. Evaluation
- B. Planning
- C. Implementation
- D. Assessment
Correct answer: D
Rationale: The correct answer is D, Assessment. In the nursing process, assessment is the first step where nurses gather subjective and objective data to understand the patient's needs. Interacting with the patient and their family to obtain subjective information is crucial in this phase. Choice A, Evaluation, comes later in the process and involves judging the effectiveness of the care provided. Choice B, Planning, is where the nurse develops a plan of care based on the assessment findings. Choice C, Implementation, is the phase where the nursing care plan is put into action.
5. Which referral would be most appropriate for the client diagnosed with thoracic outlet syndrome?
- A. The physical therapist
- B. The thoracic surgeon
- C. The occupational therapist
- D. The social worker
Correct answer: C
Rationale: The correct answer is C, the occupational therapist. An occupational therapist specializes in helping individuals with activities of daily living, ergonomic assessments, and adaptive techniques. In the case of thoracic outlet syndrome, an occupational therapist can provide exercises and adaptations to improve the client's function and alleviate symptoms. Choosing the physical therapist (choice A) may also be beneficial for rehabilitation exercises, but occupational therapists focus more on functional activities. Referring to a thoracic surgeon (choice B) would be more appropriate for surgical interventions rather than initial management. Referring to a social worker (choice D) may not directly address the physical symptoms and functional limitations associated with thoracic outlet syndrome.
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