ATI RN
Cardiovascular System Practice Exam
1. The nurse is giving nitroglycerin sublingually for chest pain. What is the most important instruction to give to the client?
- A. Place the tablet under the tongue and let it dissolve completely.
- B. Swallow the tablet whole with a glass of water.
- C. Chew the tablet and then swallow it.
- D. Take one tablet every 5 minutes until pain is relieved.
Correct answer: A
Rationale: The correct answer is A. The tablet should be placed under the tongue and allowed to dissolve completely to ensure rapid absorption. This route of administration allows the medication to be quickly absorbed into the bloodstream. Choice B is incorrect because nitroglycerin is meant to be absorbed sublingually, not swallowed. Choice C is incorrect as chewing the tablet can cause the medication to be rapidly absorbed, leading to adverse effects like a drop in blood pressure. Choice D is incorrect because the client should take only one tablet every 5 minutes up to a maximum of three tablets for chest pain relief.
2. What is a health deficit?
- A. Conditions that promote disease or injury and prevent people from realizing their health potential
- B. A health problem that can be alleviated with medical or social technology
- C. A gap between actual and achievable health status
- D. Illness of a family member
Correct answer: C
Rationale: A health deficit refers to a gap between one's current health status and the health status that could be realistically achieved. It signifies the difference between where a person's health is currently and where it could potentially be with appropriate interventions or improvements. Therefore, the correct answer is option C.
3. A nurse is assessing a client who has pericarditis. Which of the following findings is the priority?
- A. Paradoxical pulse
- B. Dependent edema
- C. Pericardial friction rub
- D. Substernal chest pain
Correct answer: A
Rationale: In a client with pericarditis, the priority finding is a paradoxical pulse. This is a crucial sign of cardiac tamponade, a life-threatening complication of pericarditis where fluid accumulates in the pericardial sac, causing compression of the heart. A paradoxical pulse is an exaggerated decrease in systolic blood pressure (>10 mmHg) during inspiration. Prompt recognition and intervention are essential to prevent hemodynamic instability and cardiac arrest. Dependent edema (choice B) is not typically associated with pericarditis. Pericardial friction rub (choice C) is a common finding in pericarditis but does not indicate the urgency of intervention as a paradoxical pulse. Substernal chest pain (choice D) is a classic symptom of pericarditis but is not as critical as a paradoxical pulse in the context of assessing for complications.
4. A client starting highly active antiretroviral therapy (HAART) for HIV infection is being educated by a nurse on preventing medication resistance. What information should the nurse provide the client about resistance?
- A. Taking low dosages of antiretroviral medication minimizes resistance.
- B. Taking one antiretroviral medication at a time minimizes resistance.
- C. Taking medication at the same time daily without missing doses minimizes resistance.
- D. Changing the medication regimen when adverse effects occur minimizes resistance.
Correct answer: C
Rationale: To prevent the development of medication resistance, it is crucial for the client to take antiretroviral medication consistently at the same time daily without missing doses. This practice helps maintain effective drug levels in the body, reducing the risk of resistance development.
5. A nurse is caring for a client who is 1 day postoperative following an open reduction and internal fixation of the right tibia. Which of the following findings should the nurse report to the provider?
- A. Serous drainage on the dressing
- B. Capillary refill of 2 seconds
- C. Heart rate of 88/min
- D. Pallor of the affected extremity
Correct answer: D
Rationale: Pallor of the affected extremity could indicate impaired circulation, such as compromised blood flow to the area, which is crucial to monitor postoperatively. This finding suggests potential vascular compromise or decreased blood supply to the extremity, which is a serious concern and should be reported promptly to the provider for further evaluation and intervention. Serous drainage on the dressing is a normal finding in the immediate postoperative period and does not necessarily indicate a complication requiring immediate provider notification. Capillary refill of 2 seconds is within the normal range (less than 3 seconds) and indicates adequate peripheral perfusion. A heart rate of 88/min is also within the normal range for an adult and is not typically a cause for immediate concern postoperatively.
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