ATI RN
Cardiovascular System Practice Exam Questions
Question 1 of 5
The client is on nitroglycerin patches. What should the nurse include in the client's education?
Correct Answer: A
Rationale: The correct answer is A: Rotate the application site with each new patch. This is important to prevent skin irritation and tolerance development. Rotating sites ensures consistent drug absorption and reduces the risk of skin reactions. Applying the patch at the same site each time (choice D) can lead to localized skin irritation. Applying the patch at the same time each day (choice B) is not as crucial as rotating sites. Leaving the patch on for 24 hours and then removing it for 12 hours (choice C) can disrupt the therapeutic effect of the medication.
Question 2 of 5
The nurse is caring for a client on warfarin with an INR of 1.8. What is the most appropriate action?
Correct Answer: D
Rationale: The correct answer is D: Monitor the client's INR closely. An INR of 1.8 indicates the client is below the therapeutic range for warfarin. By closely monitoring the client's INR, the nurse can assess the effectiveness of the current dosage and make informed decisions about potential adjustments. Increasing the dose of warfarin (Choice A) without monitoring could lead to over-anticoagulation. Administering vitamin K (Choice B) is not indicated unless the client is experiencing severe bleeding. Holding the warfarin and notifying the healthcare provider (Choice C) may be necessary in some cases, but monitoring is the initial appropriate action to evaluate the situation before making changes.
Question 3 of 5
The client on warfarin has an INR of 3.8. What is the most appropriate action by the nurse?
Correct Answer: A
Rationale: The correct answer is A: Administer vitamin K. When a client on warfarin has an INR above the therapeutic range (usually 2-3), like in this case (3.8), administering vitamin K is appropriate to reverse the anticoagulant effects. This helps prevent bleeding complications. Holding the next dose of warfarin (B) may not be sufficient to lower the INR quickly. Increasing the dose of warfarin (C) would further elevate the INR, leading to higher bleeding risk. Notifying the healthcare provider (D) is important, but immediate action with vitamin K is necessary to address the high INR.
Question 4 of 5
The nurse is giving nitroglycerin sublingually for chest pain. What is the most important instruction to give to the client?
Correct Answer: A
Rationale: The correct answer is A: Place the tablet under the tongue and let it dissolve completely. Nitroglycerin is absorbed quickly through the oral mucosa, providing rapid relief for chest pain. Placing it under the tongue allows for direct absorption into the bloodstream. Swallowing the tablet whole (B) would delay absorption. Chewing the tablet (C) would cause rapid absorption and possibly lead to a drop in blood pressure. Taking one tablet every 5 minutes (D) is not recommended as it can lead to hypotension. Therefore, option A is the most appropriate instruction for the client.
Question 5 of 5
The client is receiving digoxin and complains of nausea. What is the nurse's priority action?
Correct Answer: A
Rationale: The correct answer is A: Check the client's digoxin level. The priority action is to assess the digoxin level to determine if it is within the therapeutic range, as nausea can be a sign of digoxin toxicity. Checking the level will guide further actions. Continuing the dose without assessment (B) may worsen toxicity. Administering an antiemetic (C) only addresses the symptom, not the underlying cause. Discontinuing digoxin immediately (D) without assessing the level can be harmful if the client actually needs the medication.