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. Which term refers to high blood pressure, a condition where the force of the blood against the artery walls is too high?
- A. Hypertension
- B. Hypotension
- C. Hyperlipidemia
- D. Diabetes
Correct answer: A
Rationale: The correct answer is A, Hypertension. Hypertension is a condition characterized by persistently high blood pressure, which increases the risk of heart disease and stroke. Choice B, Hypotension, refers to low blood pressure. Choice C, Hyperlipidemia, is the term for high levels of fats in the blood. Choice D, Diabetes, is a condition characterized by high blood sugar levels.
3. 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.
4. The healthcare provider is administering IV nitroglycerin to a patient for chest pain. What is the most critical parameter to monitor?
- A. Heart rate
- B. Blood pressure
- C. Oxygen saturation
- D. Respiratory rate
Correct answer: B
Rationale: The correct answer is 'Blood pressure.' Nitroglycerin is a vasodilator that can cause a rapid drop in blood pressure, leading to hypotension. Monitoring the blood pressure is crucial to prevent potential complications such as hypotension-induced dizziness, syncope, or organ hypoperfusion. While heart rate, oxygen saturation, and respiratory rate are important parameters to monitor in a clinical setting, the immediate concern with IV nitroglycerin administration is the risk of hypotension, making blood pressure the most critical parameter to assess.
5. This term refers to a change in the inotropic state of the muscle without a change in myocardial fiber length.
- A. Contractility
- B. Excitability
- C. Refractoriness
- D. Automaticity
Correct answer: A
Rationale: The correct answer is A: Contractility. Contractility specifically refers to the change in the force of contraction of the heart muscle without changing its length. In this scenario, the focus is on the change in the inotropic state of the muscle, which directly relates to contractility. Choice B, Excitability, refers to the ability of a cell to respond to a stimulus, not specifically related to changes in contractile force. Choice C, Refractoriness, pertains to the period during which a cell is unresponsive to a new stimulus. Choice D, Automaticity, refers to the ability of cardiac cells to spontaneously generate electrical impulses.
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