ATI RN
Physical Exam Cardiovascular System
1. What is a condition where the heart's valves do not function properly, leading to disrupted blood flow within the heart?
- A. Valvular heart disease
- B. Myocarditis
- C. Endocarditis
- D. Aneurysm
Correct answer: A
Rationale: Valvular heart disease is the correct answer. It occurs when the heart's valves malfunction, leading to disrupted blood flow within the heart. Myocarditis refers to inflammation of the heart muscle, not specifically related to valve function. Endocarditis is an infection of the inner lining of the heart chambers and valves, not necessarily caused by valve malfunction. Aneurysm is the abnormal bulging of a blood vessel, not directly related to heart valve function.
2. The client is on amiodarone and reports blurred vision. What is the nurse’s best response?
- A. Reassure the client that this is a common side effect.
- B. Instruct the client to report this symptom to the healthcare provider immediately.
- C. Advise the client to stop taking the medication.
- D. Discontinue the amiodarone immediately.
Correct answer: B
Rationale: Blurred vision is a potential side effect of amiodarone. Instructing the client to report this symptom to the healthcare provider immediately is the most appropriate response. Choice A is incorrect because although blurred vision can be a common side effect of amiodarone, it should not be dismissed without further evaluation. Choice C is incorrect as advising the client to stop taking the medication without consulting the healthcare provider can be dangerous and is not the first course of action. Choice D is too drastic as discontinuing the medication should be done under the guidance of a healthcare provider after proper evaluation.
3. Which condition involves the tearing of the aorta, leading to severe pain and internal bleeding?
- A. Aortic dissection
- B. Aneurysm
- C. Stroke
- D. Myocardial infarction
Correct answer: A
Rationale: The correct answer is Aortic dissection. Aortic dissection is a life-threatening condition where the inner layer of the aorta tears, causing severe chest or back pain and internal bleeding, requiring immediate medical attention. Choice B, aneurysm, involves a bulging or weakening of a blood vessel wall, which is different from a tear in the aorta. Choices C and D, stroke and myocardial infarction, do not directly involve the tearing of the aorta and are distinct conditions.
4. The nurse is administering enoxaparin (Lovenox) to a client. What is the most important lab value to monitor?
- A. Platelet count
- B. Hemoglobin
- C. White blood cell count
- D. aPTT
Correct answer: A
Rationale: The correct answer is A: Platelet count. When administering enoxaparin, it is crucial to monitor the platelet count because enoxaparin can lead to a rare but serious side effect known as thrombocytopenia, which is a decrease in platelet levels. Monitoring the platelet count helps in detecting this adverse effect early. Choices B, C, and D are incorrect because hemoglobin, white blood cell count, and aPTT are not the most important lab values to monitor specifically for enoxaparin administration.
5. What test measures the electrical activity of the heart over a period of time, typically 24 to 48 hours?
- A. Holter monitor
- B. Echocardiogram
- C. Stress test
- D. Arterial blood gas (ABG)
Correct answer: A
Rationale: The correct answer is A, Holter monitor. A Holter monitor is a portable device that records the electrical activity of the heart over a period of 24 to 48 hours. It is used to detect arrhythmias and other heart conditions. Choice B, Echocardiogram, is a test that uses sound waves to create images of the heart's structure and function, not focused on the electrical activity. Choice C, Stress test, evaluates the heart's function under stress but does not monitor electrical activity over an extended period. Choice D, Arterial blood gas (ABG), measures the levels of oxygen and carbon dioxide in the blood, unrelated to measuring the electrical activity of the heart over time.
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