ATI RN
Physical Exam Cardiovascular System Questions
Question 1 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 2 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 3 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.
Question 4 of 5
A client on a beta blocker has a heart rate of 52 bpm. What is the nurse's priority action?
Correct Answer: A
Rationale: The correct answer is A: Hold the beta blocker and notify the healthcare provider. With a heart rate of 52 bpm, the client may be experiencing bradycardia, a potential side effect of beta blockers. Holding the medication and informing the healthcare provider is crucial to prevent further complications. Administering the beta blocker (B) can exacerbate bradycardia. Increasing the dose (C) can further decrease the heart rate. Continuing to monitor (D) without intervention can lead to worsening of the bradycardia.
Question 5 of 5
The nurse is administering a beta blocker to a client with a heart rate of 50 bpm. What is the priority action?
Correct Answer: A
Rationale: The correct answer is A because a heart rate of 50 bpm is below the normal range, and beta blockers further decrease heart rate. Holding the medication and notifying the healthcare provider is crucial to prevent potential bradycardia and adverse effects. Administering the beta blocker (choice B) can further reduce the heart rate. Decreasing the dose (choice C) may not be enough to address the issue. Monitoring the heart rate (choice D) is important but not sufficient to address the potential harm caused by administering the beta blocker.