ATI RN
Cardiovascular System Exam
1. The nurse is caring for a heart client on digoxin and notes a potassium level of 2.5. What is the appropriate priority nursing intervention?
- A. Do nothing as this is a normal potassium level.
- B. The potassium level is low so the nurse asks for an order for potassium.
- C. The nurse asks to check the digoxin level as low potassium can increase digoxin toxicity.
- D. The nurse stops the digoxin.
Correct answer: C
Rationale: The correct answer is C. When caring for a client on digoxin with a low potassium level, the priority nursing intervention is to check the digoxin level. Low potassium can increase the risk of digoxin toxicity. Checking the digoxin level will help determine if any adjustments to the medication regimen are needed to prevent potential harm. Choice A is incorrect as a potassium level of 2.5 is low, not normal. Choice B is not the priority as simply giving potassium may not address the underlying issue of potential digoxin toxicity. Choice D is not the initial action to take without assessing the digoxin level first.
2. Which procedure is used to remove excess fluid or air from the pleural space, helping to relieve pressure on the lungs?
- A. Thoracentesis
- B. Bronchoscopy
- C. Chest X-ray
- D. Arterial blood gas (ABG)
Correct answer: A
Rationale: The correct answer is Thoracentesis. Thoracentesis is a procedure specifically designed to remove excess fluid or air from the pleural space in the chest. This process helps to relieve pressure on the lungs and improve breathing. Bronchoscopy (Choice B) is a procedure used to visualize the airways and diagnose lung conditions, not to remove fluid from the pleural space. Chest X-ray (Choice C) is an imaging test that provides a picture of the structures inside the chest, including the lungs, heart, and bones. Arterial blood gas (ABG) test (Choice D) is a blood test that measures the levels of oxygen and carbon dioxide in the blood, providing information about how well the lungs are working, but it does not involve removing excess fluid or air from the pleural space.
3. When administering furosemide (Lasix) to a client, which lab value is most important to monitor?
- A. Potassium
- B. Sodium
- C. Calcium
- D. Chloride
Correct answer: A
Rationale: When administering furosemide (Lasix), it is crucial to monitor potassium levels closely. Furosemide is a loop diuretic that can lead to potassium loss, potentially causing hypokalemia. Monitoring potassium levels helps prevent adverse effects associated with low potassium, such as cardiac arrhythmias. While monitoring sodium, calcium, and chloride levels may also be important in certain situations, potassium is the most critical to monitor when administering furosemide.
4. Which condition is caused by a bacterium that primarily affects the lungs but can spread to other parts of the body?
- A. Tuberculosis
- B. Pneumonia
- C. Legionnaires' disease
- D. Histoplasmosis
Correct answer: A
Rationale: The correct answer is A, Tuberculosis. Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis, primarily affecting the lungs but can spread to other organs. Choice B, Pneumonia, is an infection that inflames the air sacs in one or both lungs. Choice C, Legionnaires' disease, is a severe form of pneumonia caused by the Legionella bacteria. Choice D, Histoplasmosis, is a fungal infection caused by inhaling spores of the Histoplasma capsulatum fungus.
5. Identify the three layers of the heart:
- A. Endocardium, Myocardium, Epicardium
- B. Epicardium, Pericardium, Endocardium
- C. Myocardium, Endocardium, Pericardium
- D. Pericardium, Myocardium, Endocardium
Correct answer: A
Rationale: The correct answer is A: Endocardium, Myocardium, Epicardium. The heart consists of three main layers: the endocardium, which lines the inner chambers of the heart; the myocardium, the middle layer responsible for the heart's pumping action; and the epicardium, the outermost layer that protects the heart. Choices B, C, and D are incorrect as they do not list the heart's layers in the correct order or combination.
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