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 symptom of chest pain worsening with deep breaths and relieved by leaning forward is indicative of pericarditis, a common complication post-MI. Auscultating for a pericardial friction rub can help confirm this diagnosis. Assessing the feet for pedal edema (Choice A) is more relevant for heart failure. Palpating radial pulses (Choice B) is not directly related to the symptom described. Checking the heart monitor for dysrhythmias (Choice D) may not provide immediate insight into the specific symptom being experienced.
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: The correct answer is B: Determine what kind of physical activities the patient usually enjoys. Rationale: 1. By determining the patient's preferred physical activities, the nurse can tailor an exercise plan that the patient is more likely to adhere to. 2. Enjoyable activities increase motivation and compliance, leading to sustained physical activity levels. 3. Personalized approach considers the patient's interests and abilities, promoting a successful and sustainable exercise routine. Summary of Incorrect Choices: A. Stressing weight loss may be discouraging and overshadow the importance of overall health benefits of exercise. C. Setting a strict time limit may not be suitable for all older adults and can hinder individualized exercise plans. D. While warming up is important, it is not the most crucial initial step in developing a personalized exercise plan.
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 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 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. For patients on warfarin therapy, INR is used to monitor the anticoagulant effect. An INR of 3 to 4 indicates a therapeutic level, reducing the risk of clot formation while minimizing the risk of bleeding. Rationale: 1. A: PTT measures intrinsic clotting pathway, not specific for warfarin monitoring. 2. B: PT measures extrinsic clotting pathway, not specific for warfarin monitoring. 3. D: HCT measures the percentage of red blood cells in blood, not related to warfarin monitoring. INR is the standard test for monitoring warfarin therapy, ensuring the effectiveness and safety of anticoagulation.
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 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.