ATI RN
Cardiovascular System Test Bank Questions
Question 1 of 5
A patient recovering from a myocardial infarction (MI) develops chest pain on day 3 that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take as focused follow-up on this symptom?
Correct Answer: C
Rationale: The correct action is to auscultate for a pericardial friction rub (Choice C). This is because the patient's symptoms of chest pain that worsens with deep breaths and improves with leaning forward suggest pericarditis, a common complication post-MI. A pericardial friction rub is a classic sign of pericarditis. Assessing the feet for pedal edema (Choice A) is not relevant to the presenting symptoms. Palpating radial pulses bilaterally (Choice B) and checking the heart monitor for dysrhythmias (Choice D) are not the priority in this situation.
Question 2 of 5
To improve the physical activity level for a mildly obese 71-yr-old patient, which action should the nurse plan to take?
Correct Answer: B
Rationale: To improve physical activity for a mildly obese 71-yr-old patient, the nurse should determine what physical activities the patient enjoys. This approach considers the patient's preferences, increasing the likelihood of adherence. Stressing weight loss (A) may not be motivating for everyone. Limiting exercise time (C) is not evidence-based. A warm-up (D) is important but not the initial step.
Question 3 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 4 of 5
A nurse administers warfarin (Coumadin) to a client with deep vein thrombophlebitis. Which laboratory valve indicates that the client has a therapeutic level of warfarin?
Correct Answer: C
Rationale: The correct answer is C: International Normalized Ratio (INR) of 3 to 4. INR is the standard measurement of the time it takes for blood to clot. For clients on warfarin therapy, a therapeutic INR range is typically between 2 to 3 for most indications. However, in the case of deep vein thrombophlebitis, a slightly higher range of 3 to 4 is often targeted. This range ensures adequate anticoagulation to prevent clot formation without increasing the risk of bleeding excessively. Now, let's analyze why the other choices are incorrect: A: Partial thromboplastin time (PTT) is used to monitor heparin therapy, not warfarin. B: Prothrombin time (PT) is used to monitor warfarin therapy, but the correct therapeutic range is typically 1.5 to 2.5 times the control, not 1.5 to 2 times. D
Question 5 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.