the nurse is giving a client an iv bolus of heparin what is the most important nursing action
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Nursing Elites

ATI RN

Cardiovascular System Practice Exam

1. The nurse is giving a client an IV bolus of heparin. What is the most important nursing action?

Correct answer: A

Rationale: When administering an IV bolus of heparin, the most important nursing action is to monitor the client's heart rate. Heparin can cause bradycardia as a side effect, making it crucial to assess the heart rate for any abnormalities. Checking the blood pressure (Choice B) is important but not as critical as monitoring the heart rate. While checking for signs of bleeding (Choice C) is essential, it is not the most crucial action when administering heparin. Monitoring the respiratory rate (Choice D) is also important but not as directly related to the potential side effects of heparin as monitoring the heart rate.

2. What is the ability of cardiac cells to respond to an impulse by contracting?

Correct answer: A

Rationale: Excitability is the correct term that describes the ability of cardiac cells to respond to an impulse by contracting. Excitability refers to the cell's ability to respond to stimuli and generate an action potential. Choice B, Contractility, is incorrect as it refers to the ability of cardiac cells to contract after receiving a stimulus, not the response to the impulse itself. Choice C, Rhythmicity, is incorrect as it pertains to the heart's ability to contract rhythmically without external stimulation. Choice D, Conductivity, is incorrect as it refers to the ability of cardiac cells to transmit an impulse from cell to cell, not the direct response to the impulse by contracting.

3. This is a procedure where a small mesh tube is inserted into an artery to keep it open and improve blood flow.

Correct answer: A

Rationale: Stent placement is a procedure where a small mesh tube (stent) is inserted into an artery to keep it open and improve blood flow, often following angioplasty.

4. When administering furosemide (Lasix) to a client, which lab value is most important to monitor?

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.

5. What is a surgical procedure to remove one of the lobes of the lungs, often performed to treat lung cancer?

Correct answer: A

Rationale: A lobectomy is the correct answer. This surgical procedure involves removing one of the lobes of the lungs, commonly done to treat lung cancer or other serious lung ailments. Choice B, pneumonectomy, involves the complete removal of a lung, not just a lobe. Choice C, thoracotomy, is a surgical incision into the chest wall and is not specific to removing a lung lobe. Choice D, tracheostomy, is the creation of an opening in the windpipe to assist with breathing and is unrelated to lung lobe removal.

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