ATI RN
Physical Exam Cardiovascular System
1. Which of the following is a type of heart attack that occurs when the blood supply to part of the heart muscle is severely reduced or stopped?
- A. Myocardial infarction
- B. Angina
- C. Stroke
- D. Congestive heart failure
Correct answer: A
Rationale: The correct answer is A: Myocardial infarction. Myocardial infarction, commonly known as a heart attack, occurs when the blood supply to part of the heart muscle is severely reduced or stopped, leading to tissue damage or death. Angina (choice B) is chest pain or discomfort that occurs when the heart muscle doesn't get enough oxygen-rich blood. Stroke (choice C) is a condition where the blood supply to the brain is interrupted or reduced. Congestive heart failure (choice D) is a chronic condition where the heart muscle doesn't pump blood as well as it should.
2. Which order should the nurse question?
- A. The addition of a loop diuretic with digoxin.
- B. The addition of a beta blocker with digoxin.
- C. A digoxin dose of 0.125 mg per day.
- D. The addition of an ACE inhibitor with digoxin.
Correct answer: B
Rationale: The correct answer is B because adding a beta blocker to digoxin can potentiate the bradycardic effect of digoxin, leading to serious complications such as heart block. This combination requires caution as it can significantly slow down the heart rate. Choices A, C, and D are not the best options to question in this scenario. Loop diuretics are commonly used with digoxin, a digoxin dose of 0.125 mg per day is within the typical range, and ACE inhibitors are often prescribed alongside digoxin for managing heart conditions.
3. The client on nitroglycerin patches reports dizziness when standing up. What is the nurse’s best response?
- A. Advise the client to rise slowly to prevent dizziness.
- B. Instruct the client to discontinue the nitroglycerin patches.
- C. Encourage the client to rest and avoid physical activity.
- D. Suggest the client take an over-the-counter antiemetic.
Correct answer: A
Rationale: The correct answer is to advise the client to rise slowly to prevent dizziness. Dizziness when standing up can be a sign of orthostatic hypotension, a common side effect of nitroglycerin. Rising slowly can help minimize this symptom. Instructing the client to discontinue the nitroglycerin patches (Choice B) is not appropriate without consulting a healthcare provider as sudden discontinuation can lead to adverse effects. Encouraging the client to rest and avoid physical activity (Choice C) does not address the specific issue of orthostatic hypotension. Suggesting the client take an over-the-counter antiemetic (Choice D) is not indicated for dizziness related to orthostatic hypotension.
4. The client is receiving intravenous dopamine. What is the most important nursing assessment?
- A. Monitor heart rate and rhythm
- B. Monitor blood pressure
- C. Monitor respiratory rate
- D. Monitor oxygen saturation
Correct answer: A
Rationale: The correct answer is to monitor heart rate and rhythm when a client is receiving intravenous dopamine. Dopamine is known to potentially cause arrhythmias, making this assessment crucial. While monitoring blood pressure, respiratory rate, and oxygen saturation are important nursing assessments, they are not the most critical when dopamine is being administered.
5. Which test measures how much and how quickly you can move air out of your lungs?
- A. Spirometry
- B. Peak flow meter
- C. Lung volume test
- D. Arterial blood gas
Correct answer: A
Rationale: The correct answer is A, Spirometry. Spirometry is a common pulmonary function test that measures lung function by assessing the amount (volume) and speed (flow) of air that can be inhaled and exhaled. This test helps in diagnosing conditions like asthma, chronic obstructive pulmonary disease (COPD), and other lung diseases. Peak flow meter (choice B) measures the maximum speed at which a person can exhale air, mainly used in asthma management. Lung volume test (choice C) evaluates the total amount of air the lungs can hold. Arterial blood gas (choice D) measures the levels of oxygen and carbon dioxide in the blood, providing information on how well the lungs are functioning in gas exchange, but it does not specifically measure the amount and speed of air movement in and out of the lungs like spirometry does.
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