ATI RN
Physical Exam Cardiovascular System
1. What test measures the electrical activity of the heart and can detect heart rhythm problems?
- A. Electrocardiogram (ECG or EKG)
- B. Chest X-ray
- C. MRI
- D. CT scan
Correct answer: A
Rationale: The correct answer is Electrocardiogram (ECG or EKG). An electrocardiogram is a test that measures the electrical activity of the heart and can detect irregularities in heart rhythm. Choices B, C, and D are incorrect because a chest X-ray, MRI, and CT scan do not specifically measure the electrical activity of the heart or detect heart rhythm problems.
2. The nurse is administering a beta blocker to a client with a heart rate of 58 bpm. What is the nurse’s priority action?
- A. Administer the beta blocker as ordered.
- B. Hold the beta blocker and notify the healthcare provider.
- C. Increase the dose of the beta blocker.
- D. Monitor the client’s heart rate and reassess in 30 minutes.
Correct answer: B
Rationale: The correct answer is B. A heart rate of 58 bpm is considered low, and beta blockers can further decrease the heart rate. Therefore, the nurse's priority action should be to hold the beta blocker and notify the healthcare provider for further assessment. Choice A is incorrect because administering the beta blocker without considering the low heart rate can worsen the condition. Choice C is incorrect as increasing the dose of the beta blocker can lead to further slowing of the heart rate, which is not safe in this situation. Choice D is not the priority action; holding the medication and seeking guidance from the healthcare provider is more crucial.
3. The client on furosemide (Lasix) is at risk for which electrolyte imbalance?
- A. Hyperkalemia
- B. Hypokalemia
- C. Hyponatremia
- D. Hypernatremia
Correct answer: B
Rationale: The correct answer is B: Hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss, resulting in hypokalemia. This electrolyte imbalance is a significant risk associated with diuretic use. Choices A, C, and D are incorrect. Hyperkalemia (choice A) is not typically associated with furosemide use. Hyponatremia (choice C) and hypernatremia (choice D) are related to sodium levels, not potassium levels affected by furosemide.
4. The client is on spironolactone (Aldactone). What is the most important dietary instruction?
- A. Avoid foods high in potassium.
- B. Increase intake of foods high in potassium.
- C. Avoid foods high in sodium.
- D. Increase intake of foods high in sodium.
Correct answer: A
Rationale: The correct answer is to avoid foods high in potassium. Spironolactone is a potassium-sparing diuretic, meaning it helps the body retain potassium and can lead to hyperkalemia if too much potassium is consumed. Choices B, C, and D are incorrect because increasing intake of potassium-rich foods can worsen hyperkalemia, while avoiding foods high in sodium is not the primary concern when taking spironolactone.
5. What does the PR interval measure?
- A. Time it takes for the electrical impulse to travel from the atria to the ventricles
- B. Measurement of ventricular depolarization
- C. Duration of ventricular repolarization
- D. Segment representing the time between ventricular depolarization and repolarization
Correct answer: A
Rationale: The PR interval measures the time it takes for the electrical impulse to travel from the atria to the ventricles. It is crucial in diagnosing heart rhythm disorders, as abnormalities in this interval can indicate conduction abnormalities between the atria and ventricles. Choices B, C, and D are incorrect. The QRS complex represents ventricular depolarization, the QT interval represents the duration of ventricular repolarization, and the ST segment represents the time between ventricular depolarization and repolarization.
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