ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 33 Questions
Question 1 of 5
A nurse assesses an older adult client who has multiple chronic diseases. The client's heart rate is 48 beats/min. Which action should the nurse take first?
Correct Answer: C
Rationale: Bradycardia in older adults can result from a decrease in pacemaker cells or medication effects. The nurse should first assess the client's medications, as certain drugs (e.g., beta blockers) can cause a low heart rate. This step precedes documentation, pacing, or administering atropine.
Question 2 of 5
A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure should the nurse assess? (Select all that apply.)
Correct Answer: A,C,E
Rationale: Right-sided heart catheterization carries risks of thrombophlebitis, relationships pulmonary embolism, and cardiac tamponade. Stroke and myocardial infarction are more commonly associated with left-sided catheterizations.
Question 3 of 5
Where should the nurse auscultate the aortic valve?
Correct Answer: A
Rationale: The aortic valve is best auscultated in the second intercostal space just to the right of the sternum, where heart sounds related to aortic flow are most audible.
Question 4 of 5
A nurse monitors a client 2 hours after a cardiac catheterization. Which findings would require immediate action? (Select all that apply.)
Correct Answer: B,D,E
Rationale: Hypokalemia (2.9 mEq/L), an expanding hematoma, and rhythm changes are serious complications requiring immediate action. Slightly elevated blood pressure and warmth/redness (if not severe) are less urgent in the immediate post-procedure period.
Question 5 of 5
A nurse prepares a client with acute renal insufficiency for a cardiac catheterization. The provider prescribes 0.9% normal saline to infuse at 125 mL/h for renal protection. The nurse obtains gravity tubing with a drip rate of 15 drops/mL. At what rate (drops/min) should the nurse infuse the fluids?
Correct Answer: B
Rationale:
To calculate the drip rate: (125 mL/h ? 15 drops/mL) ÷ 60 min/h = 31.25 drops/min. Rounding to the nearest whole number gives 31 drops/min.