ATI RN
Physical Exam Cardiovascular System Questions
Question 1 of 5
The client on nitroglycerin complains of a headache. How does the nurse explain this?
Correct Answer: A
Rationale: The correct answer is A: This is a normal side effect of nitroglycerin. Nitroglycerin is a vasodilator that relaxes blood vessels, including those in the head, leading to headaches. The nurse should explain that this is a common and expected side effect of the medication. B: This is incorrect because a headache from nitroglycerin is not indicative of an allergic reaction. C: This is incorrect as a headache is not typically a sign of overdose with nitroglycerin. D: This is incorrect as a headache from nitroglycerin is not specifically linked to heart failure.
Question 2 of 5
The client on clopidogrel (Plavix) should be monitored for which adverse effect?
Correct Answer: A
Rationale: The correct answer is A: Bleeding. Clopidogrel is an antiplatelet medication that can increase the risk of bleeding due to its mechanism of action in preventing blood clot formation. Monitoring for signs of bleeding such as easy bruising, prolonged bleeding from cuts, blood in urine or stool is crucial. Incorrect Choices: B: Hypertension - Clopidogrel does not typically cause hypertension. C: Tachycardia - Clopidogrel does not affect heart rate in a way that would lead to tachycardia. D: Bradycardia - Clopidogrel is not associated with causing bradycardia. In summary, monitoring for bleeding is essential when a client is on clopidogrel due to its antiplatelet effects, while hypertension, tachycardia, and bradycardia are not typically associated adverse effects of this medication.
Question 3 of 5
The nurse is administering digoxin to a client. What is the most important parameter to check before administration?
Correct Answer: A
Rationale: The correct answer is A: Heart rate. Before administering digoxin, it is crucial to check the client's heart rate because digoxin is a medication that affects the heart. Monitoring the heart rate helps assess the client's cardiac function and determines if the medication can be safely given. Checking heart rate ensures that the client is not at risk for potential adverse effects such as bradycardia or arrhythmias. Blood pressure (B), respiratory rate (C), and oxygen saturation (D) are important parameters to monitor but are not as directly related to the action of digoxin on the heart.
Question 4 of 5
The client on digoxin has a potassium level of 3.0 mEq/L. What is the nurse's priority action?
Correct Answer: B
Rationale: The correct answer is B: Hold the digoxin and notify the healthcare provider. A potassium level of 3.0 mEq/L can increase the risk of digoxin toxicity as hypokalemia potentiates its effects. Holding the digoxin and informing the healthcare provider allows for further assessment and possible adjustment of the medication regimen. Administering a potassium supplement (A) without adjusting the digoxin dose can still lead to toxicity. Continuing the current digoxin dose (C) without addressing the low potassium level puts the client at risk. Administering Digibind (D) is not necessary at this point as the priority is to address the low potassium level and prevent digoxin toxicity.
Question 5 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.