ATI RN
Physical Exam Cardiovascular System Questions
Question 1 of 5
The client is prescribed warfarin. What should the client be taught about this medication?
Correct Answer: A
Rationale: The correct answer is A: Avoid foods high in vitamin K. Warfarin is an anticoagulant that works by decreasing the blood's ability to clot. Vitamin K is essential for blood clotting, so consuming foods high in vitamin K can interfere with the medication's effectiveness. It is important for the client to maintain a consistent intake of vitamin K to ensure the medication works properly. Choices B, C, and D are incorrect because taking warfarin with food, at the same time daily, or increasing the dose if a dose is missed can result in adverse effects or reduced effectiveness of the medication.
Question 2 of 5
The client on spironolactone (Aldactone) has a potassium level of 5.6 mEq/L. What is the nurse's priority action?
Correct Answer: A
Rationale: The correct answer is A: Hold the spironolactone and notify the healthcare provider. A potassium level of 5.6 mEq/L is elevated (normal range is 3.5-5.0 mEq/L). Spironolactone is a potassium-sparing diuretic, so the priority action is to hold the medication to prevent further elevation of potassium levels, which can lead to serious cardiac arrhythmias. Notifying the healthcare provider is crucial for further management. Administering potassium supplements (B) would further increase potassium levels. Continuing spironolactone as ordered (C) would exacerbate hyperkalemia. Increasing the dose of spironolactone (D) would be contraindicated in this situation.
Question 3 of 5
The nurse is administering a beta blocker to a client with a heart rate of 58 bpm. What is the nurse's priority action?
Correct Answer: B
Rationale: The correct answer is B. Holding the beta blocker and notifying the healthcare provider is the priority action because a heart rate of 58 bpm may be too low to safely administer a beta blocker, which can further decrease heart rate and lead to complications like bradycardia or heart block. Increasing the dose (choice C) without assessing the current heart rate is risky. Administering the beta blocker as ordered (choice A) without considering the low heart rate is unsafe. Monitoring the client's heart rate (choice D) is important but not the priority when the initial heart rate is low.
Question 4 of 5
The client on furosemide (Lasix) is complaining of muscle cramps. What electrolyte imbalance should the nurse suspect?
Correct Answer: D
Rationale: The correct answer is D: Hypokalemia. Furosemide is a loop diuretic that causes potassium excretion, leading to low potassium levels and muscle cramps. Hypokalemia is associated with muscle weakness and cramps due to altered muscle function. Hyperkalemia (A) is high potassium levels, not typically associated with furosemide. Hyponatremia (B) is low sodium levels, not directly related to furosemide use. Hypocalcemia (C) is low calcium levels, which can cause muscle cramps but is not the most likely electrolyte imbalance with furosemide.
Question 5 of 5
The nurse is caring for a client on warfarin with an INR of 5.2. What is the most appropriate action?
Correct Answer: A
Rationale: The correct answer is A: Administer vitamin K as an antidote. A high INR level of 5.2 indicates the client is at risk of bleeding due to excess anticoagulation from warfarin. Vitamin K helps reverse the effects of warfarin by promoting clotting factor production. Administering vitamin K is crucial to prevent bleeding complications. Holding the next dose of warfarin (B) is not enough to rapidly lower the INR. Increasing the dose of warfarin (C) would worsen the situation. Monitoring the client's INR closely (D) is important, but immediate action with vitamin K is necessary in this case.