ATI RN
Cardiovascular System Test Bank Questions
Question 1 of 5
A nurse is evaluating a client with left- sided heart failure. Which finding should the nurse expect to assess?
Correct Answer: B
Rationale: The correct answer is B: Dyspnea. Left-sided heart failure commonly presents with dyspnea due to fluid accumulation in the lungs (pulmonary edema). This occurs because the weakened left ventricle cannot efficiently pump blood to the body, causing fluid to back up into the lungs. Ascites (A) is more commonly associated with right-sided heart failure. Hepatomegaly (C) and jugular vein distention (D) are signs of right-sided heart failure, not left-sided heart failure. Dyspnea is a hallmark symptom of left-sided heart failure due to pulmonary congestion.
Question 2 of 5
An infant with a congenital cyanotic heart defect has a complete blood count drawn, revealing an elevated red blood cell (RBC) count. Which condition do these findings indicate?
Correct Answer: D
Rationale: The elevated RBC count in an infant with a congenital cyanotic heart defect indicates the body's response to chronic hypoxia by producing more RBCs to compensate for decreased oxygen levels. This is known as hypoxia compensation. Anemia (choice A) is characterized by decreased RBC count, dehydration (choice B) does not typically cause elevated RBC count, and jaundice (choice C) is related to liver function and bilirubin levels, not RBC count.
Question 3 of 5
A client undergoes ligation of varicose veins. The nurse includes in the plan of care which of the following important interventions for the nursing diagnosis of ineffective tissue perfusion?
Correct Answer: B
Rationale: Rationale for Choice B (Correct Answer): Flexing lower extremities four times a day helps promote circulation and prevent blood stasis, aiding in tissue perfusion after vein ligation. Rationale for why other choices are incorrect: A: Removing compression stockings can hinder venous return and worsen tissue perfusion. C: Numbness is not a normal finding post-vein ligation and should be promptly reported. D: Briskly scrubbing lower extremities can damage the skin and impair circulation, worsening tissue perfusion.
Question 4 of 5
During the acute phase of rheumatic fever, which of the following is a priority action of the nurse?
Correct Answer: B
Rationale: The correct answer is B: Assess for early signs of endocarditis. During the acute phase of rheumatic fever, endocarditis can develop as a complication due to the inflammation and damage to the heart valves. Early detection of endocarditis is crucial to prevent serious complications. By assessing for early signs such as new or changing heart murmurs, fever, fatigue, and shortness of breath, the nurse can promptly intervene and prevent further damage to the heart valves. Encouraging ambulation, maintaining hydration, and managing pain are important aspects of care but assessing for endocarditis takes precedence due to its potential impact on the patient's health and outcomes.
Question 5 of 5
A patient is admitted with severe uncompensated pulmonary edema secondary to chronic heart failure. After diagnostic testing, it is found that the left coronary artery is blocked, which has led to his pulmonary edema. Which of the following signs and symptoms is consistent with this diagnosis?
Correct Answer: C
Rationale: The correct answer is C: Elevated pulmonary artery wedge pressure (PAWP) or PAOP. In this scenario, the left coronary artery blockage has led to decreased cardiac function, causing increased pressure in the pulmonary circulation leading to pulmonary edema. PAWP reflects left ventricular end-diastolic pressure, which is elevated in conditions like heart failure. Elevated central venous pressure (A) may be seen in heart failure but is not specific to this diagnosis. Elevated blood pressure (B) is not typically associated with uncompensated heart failure. Increased oxygen saturation (D) is not consistent with the diagnosis, as pulmonary edema often leads to decreased oxygen saturation due to impaired gas exchange.