ATI RN
Cardiovascular System Practice Exam Questions
Question 1 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 2 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.
Question 3 of 5
The client on digoxin has a potassium level of 2.7 mEq/L. What is the nurse's priority action?
Correct Answer: A
Rationale: The correct answer is A: Hold the digoxin and notify the healthcare provider. A potassium level of 2.7 mEq/L is below the normal range (3.5-5.0 mEq/L), which can increase the risk of digoxin toxicity. Holding the digoxin and informing the healthcare provider is crucial to prevent potential harm. Administering the digoxin (choice B) can exacerbate toxicity symptoms. Increasing the dose of digoxin (choice C) is contraindicated due to the low potassium level. Administering potassium supplements (choice D) may be necessary, but the priority is to address the digoxin therapy first.
Question 4 of 5
The nurse is giving digoxin to a client. What is the most important parameter to check before administration?
Correct Answer: A
Rationale: Step 1: Digoxin is primarily used to treat heart conditions. Step 2: Heart rate is crucial as digoxin can affect the heart rhythm. Step 3: Monitoring heart rate ensures safety and effectiveness of digoxin. Step 4: Blood pressure, respiratory rate, and oxygen saturation are important but not as directly impacted by digoxin.
Question 5 of 5
The client is on spironolactone (Aldactone) and has a potassium level of 5.9 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. Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia. With a potassium level of 5.9 mEq/L, the client is at risk for serious complications like cardiac arrhythmias. The priority action is to stop the medication to prevent further elevation of potassium levels and inform the healthcare provider for further management. Administering potassium supplements (B) would worsen the hyperkalemia. Continuing spironolactone (C) or increasing the dose (D) would be inappropriate and potentially harmful in this situation.