ATI RN
Physical Exam Cardiovascular System
1. What is a chronic condition where the heart is unable to pump blood effectively, leading to fluid buildup in the lungs and other parts of the body?
- A. Heart failure
- B. Myocardial infarction
- C. Pericarditis
- D. Pulmonary edema
Correct answer: A
Rationale: The correct answer is A: Heart failure. Heart failure is a chronic condition characterized by the heart's inability to pump blood effectively, resulting in fluid accumulation in the lungs and other body tissues. Myocardial infarction (choice B) refers to a heart attack caused by a blocked coronary artery, leading to damage of heart muscle tissue. Pericarditis (choice C) is the inflammation of the pericardium, the protective sac around the heart. Pulmonary edema (choice D) is a condition where fluid builds up in the lungs, often as a result of heart failure.
2. The client is on warfarin and has an INR of 1.5. What is the nurse’s priority action?
- A. Increase the dose of warfarin.
- B. Hold the next dose of warfarin.
- C. Continue the current dose of warfarin.
- D. Monitor the client’s INR closely.
Correct answer: B
Rationale: An INR of 1.5 is below the therapeutic range for a client on warfarin, indicating that the client may be at risk of clot formation. The nurse's priority action should be to hold the next dose of warfarin to prevent further reduction of the INR. Increasing the dose could potentially lead to an increased risk of bleeding, and continuing the current dose may not be sufficient to bring the INR within the therapeutic range. Monitoring the client's INR closely is important but not the priority action in this scenario.
3. The nurse is giving a client an IV bolus of heparin. What is the most important nursing action?
- A. Monitor the client's heart rate.
- B. Check the client's blood pressure.
- C. Check for signs of bleeding.
- D. Monitor the client's respiratory rate.
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.
4. Which of the following is a chronic inflammatory disease of the airways that causes episodes of wheezing, breathlessness, chest tightness, and coughing?
- A. Asthma
- B. Bronchitis
- C. Pneumonia
- D. Emphysema
Correct answer: A
Rationale: Asthma is the correct answer. It is a chronic inflammatory disease of the airways characterized by episodes of wheezing, breathlessness, chest tightness, and coughing. These symptoms are often triggered by allergens or exercise. Bronchitis is an inflammation of the bronchial tubes, but it is not typically chronic or involve the same triggers as asthma. Pneumonia is an infection of the lungs, and emphysema is a type of chronic obstructive pulmonary disease (COPD) often caused by smoking.
5. What structures hold up the AV valves and are anchored to the ventricular wall by the papillary muscles?
- A. Chordae tendineae
- B. Papillary muscles
- C. Semilunar valves
- D. Aortic valve
Correct answer: A
Rationale: The correct answer is A: Chordae tendineae. Chordae tendineae are fibrous cords that connect the AV valves to the papillary muscles, preventing the valves from inverting during ventricular contraction. Papillary muscles (choice B) anchor the chordae tendineae to the ventricular wall but do not hold up the AV valves directly. Semilunar valves (choice C) are located between the ventricles and the major arteries and are not involved in holding up the AV valves. The aortic valve (choice D) is one of the semilunar valves and is not responsible for holding up the AV valves.
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