ATI RN
Physical Exam Cardiovascular System
1. What is a condition where the lung's alveoli are permanently enlarged and damaged, leading to shortness of breath?
- A. Emphysema
- B. Bronchitis
- C. Atelectasis
- D. Pulmonary fibrosis
Correct answer: A
Rationale: Emphysema is the correct answer. It is a chronic lung condition characterized by the permanent enlargement and damage of the alveoli, leading to shortness of breath and impaired oxygen exchange. Bronchitis is the inflammation of the bronchial tubes, not specifically related to alveolar damage. Atelectasis is the collapse of lung tissue, not enlargement. Pulmonary fibrosis involves scarring and thickening of lung tissue, different from the alveolar damage seen in emphysema.
2. The client on spironolactone (Aldactone) has a potassium level of 5.8 mEq/L. What is the nurse’s priority action?
- A. Hold the spironolactone and notify the healthcare provider.
- B. Administer a potassium supplement.
- C. Continue the spironolactone as ordered.
- D. Increase the dose of spironolactone.
Correct answer: A
Rationale: With a potassium level of 5.8 mEq/L, which is high, the priority action for the nurse is to hold the spironolactone. Spironolactone is a potassium-sparing diuretic that can further increase potassium levels. Therefore, it is crucial to prevent exacerbating hyperkalemia by discontinuing the medication. Notifying the healthcare provider is necessary for further guidance and potential adjustments to the treatment plan. Administering a potassium supplement (Choice B) would be contraindicated since the client already has elevated potassium levels. Continuing the spironolactone as ordered (Choice C) can worsen hyperkalemia. Increasing the dose of spironolactone (Choice D) would be unsafe and exacerbate the high potassium levels.
3. What is a chronic lung disease that includes chronic bronchitis and emphysema?
- A. Chronic Obstructive Pulmonary Disease (COPD)
- B. Pneumonia
- C. Asthma
- D. Tuberculosis
Correct answer: A
Rationale: The correct answer is Chronic Obstructive Pulmonary Disease (COPD). COPD is a chronic lung condition that encompasses chronic bronchitis and emphysema, causing airflow obstruction from the lungs. Pneumonia (choice B) is an infection in the lungs, while asthma (choice C) is characterized by airway inflammation and constriction. Tuberculosis (choice D) is a bacterial infection that primarily affects the lungs but is distinct from COPD.
4. The client on enoxaparin (Lovenox) is scheduled for surgery. What is the nurse’s priority action?
- A. Hold the enoxaparin and notify the healthcare provider.
- B. Administer the enoxaparin as scheduled.
- C. Administer vitamin K before the surgery.
- D. Monitor the client’s INR and proceed with surgery.
Correct answer: A
Rationale: The correct answer is A: Hold the enoxaparin and notify the healthcare provider. Enoxaparin, being an anticoagulant, should be held before surgery to reduce the risk of excessive bleeding during the procedure. It is crucial to inform the healthcare provider to determine the appropriate management plan. Choice B is incorrect because administering enoxaparin before surgery can increase the risk of bleeding. Choice C is incorrect as vitamin K administration is not typically indicated in this situation. Choice D is incorrect because monitoring the client's INR and proceeding with surgery without addressing the enoxaparin can lead to significant bleeding complications.
5. What is a condition where the airways become swollen and produce extra mucus, making it difficult to breathe, often associated with COPD?
- A. Chronic bronchitis
- B. Pneumonia
- C. Emphysema
- D. Tuberculosis
Correct answer: A
Rationale: Chronic bronchitis is the correct answer. It is a long-term inflammation of the bronchi, leading to persistent cough and mucus production, commonly associated with chronic obstructive pulmonary disease (COPD). Pneumonia (Choice B) is an infection that inflames the air sacs in one or both lungs. Emphysema (Choice C) is a lung condition where the air sacs in the lungs are damaged, making it difficult to breathe. Tuberculosis (Choice D) is a bacterial infection that primarily affects the lungs.
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