ATI RN
Cardiovascular System Practice Exam Questions
Question 1 of 5
The client is receiving intravenous dopamine. What is the most important nursing assessment?
Correct Answer: A
Rationale: The correct answer is A: Monitor heart rate and rhythm. Dopamine is a medication that can affect the heart rate and rhythm. Monitoring these parameters is crucial to detect any potential adverse effects such as tachycardia or arrhythmias. Monitoring blood pressure is also important, but assessing heart rate and rhythm takes precedence due to the direct impact of dopamine on cardiac function. Respiratory rate and oxygen saturation are generally not directly affected by dopamine administration.
Question 2 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 3 of 5
The client is on spironolactone (Aldactone). What is the most important dietary instruction?
Correct Answer: A
Rationale: The correct answer is A: Avoid foods high in potassium. Spironolactone is a potassium-sparing diuretic that can increase potassium levels in the body. Consuming foods high in potassium while on spironolactone can lead to hyperkalemia, which can be dangerous. By avoiding foods high in potassium, the client can help maintain a safe potassium level. Summary: - Choice B (Increase intake of foods high in potassium) is incorrect because it can lead to hyperkalemia when combined with spironolactone. - Choice C (Avoid foods high in sodium) is unrelated to spironolactone's mechanism of action. - Choice D (Increase intake of foods high in sodium) is incorrect as it is not relevant to the dietary instruction needed for a client on spironolactone.
Question 4 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 5 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.