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 typically results in the accumulation of fluid in the lungs, leading to difficulty breathing or dyspnea. This is due to the impaired ability of the left side of the heart to pump blood efficiently, causing fluid backup into the lungs. Ascites (choice A) is more commonly associated with right-sided heart failure. Hepatomegaly (choice C) and jugular vein distention (choice D) are also more indicative of right-sided heart failure. Therefore, based on the pathophysiology of left-sided heart failure, dyspnea is the expected finding.
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 correct answer is D: Hypoxia compensation. In a cyanotic heart defect, there is decreased oxygenation, leading to hypoxia. The body compensates by increasing RBC production to improve oxygen-carrying capacity. Anemia (choice A) is a decrease in RBC count, not an increase. Dehydration (choice B) would typically lead to hemoconcentration but not specifically an elevated RBC count. Jaundice (choice C) is due to elevated bilirubin levels, unrelated to RBC count. Therefore, the elevated RBC count in this infant indicates a compensatory response to hypoxia, supporting choice D.
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: Step 1: Flexing the lower extremities helps promote blood circulation and prevents blood clot formation post-vein ligation. Step 2: Increased movement aids in preventing stasis and promotes tissue perfusion. Step 3: Flexing exercises can prevent complications such as deep vein thrombosis. Step 4: Removing compression stockings, numbness, and brisk scrubbing do not directly address tissue perfusion or circulation issues.
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 because during the acute phase of rheumatic fever, the priority action of the nurse is to assess for early signs of endocarditis due to the risk of developing heart valve damage. Endocarditis is a serious complication of rheumatic fever that can lead to further cardiac issues. Monitoring for signs such as new or changing heart murmurs, fever, and signs of embolization is crucial for early detection and intervention. Choice A is incorrect because although ambulation is important for overall health, it is not the priority during the acute phase of rheumatic fever. Choice C is also incorrect as maintaining hydration is essential, but it is not the priority over monitoring for endocarditis. Choice D is incorrect as managing pain with strong narcotic analgesics is not the priority action during the acute phase of rheumatic fever.
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 blockage in the left coronary artery is causing a decrease in cardiac output, leading to heart failure and pulmonary edema. Elevated PAWP indicates increased pressure in the left side of the heart, reflecting the back pressure that causes fluid to leak into the lungs. A: Elevated central venous pressure is more indicative of right heart failure, not directly related to left coronary artery blockage. B: Elevated blood pressure is not typically associated with pulmonary edema from left coronary artery blockage. D: Increased oxygen saturation would not be a typical finding in pulmonary edema due to decreased gas exchange in the lungs.