ATI RN
Med Surg Cardiovascular Practice Questions Questions
Question 1 of 5
The nurse is admitting a patient who has chest pain. Which assessment data suggest that the pain is caused by an acute myocardial infarction (AMI)?
Correct Answer: B
Rationale: The correct answer is B because chest pain lasting longer than 30 minutes is a key indicator of an acute myocardial infarction (AMI) due to the prolonged ischemia of the heart muscle. Choice A is incorrect because chest pain increasing with deep breathing is more indicative of pleuritic chest pain, not AMI. Choice C is incorrect because relief with nitroglycerin suggests the pain is due to angina, not AMI. Choice D is incorrect because reproducible pain with arm movement is more likely musculoskeletal in nature, not related to AMI.
Question 2 of 5
The nurse is caring for a patient who was admitted to the coronary care unit following an acute myocardial infarction (AMI) and percutaneous coronary intervention the previous day. Teaching for this patient would include
Correct Answer: A
Rationale: The correct answer is A because teaching the patient about when cardiac rehabilitation will begin is crucial for their recovery post-AMI and percutaneous coronary intervention. Cardiac rehabilitation plays a vital role in improving outcomes and quality of life for these patients. Option B, C, and D are incorrect as emotional responses to AMI, information regarding discharge medications, and pathophysiology of coronary artery disease are important but not the immediate priority for a patient in this situation.
Question 3 of 5
A patient had a non–ST-segment-elevation myocardial infarction (NSTEMI) 3 days ago. Which nursing intervention included in the plan of care is appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)?
Correct Answer: D
Rationale: The correct answer is D: Reinforcement of teaching about the purpose of prescribed medications. This task can be safely delegated to an experienced LPN/LVN as it involves providing information that has already been taught by the RN. The LPN/LVN can reinforce the teaching without interpreting or altering the content. This task does not require critical thinking or assessment skills beyond the scope of practice for an LPN/LVN. A, evaluation of the patient's response to walking in the hallway, involves physical assessment and monitoring for any adverse signs or symptoms, which requires the RN's expertise. B, completion of the referral form for a home health nurse follow-up, involves coordination of care and decision-making, which falls under the RN's responsibility. C, education of the patient about the pathophysiology of heart disease, involves complex medical information and understanding, which is beyond the scope of practice for an LPN/LVN.
Question 4 of 5
A nurse administers heparin to a client with deep vein thrombophlebitis. Which laboratory value should the nurse monitor to determine the effectiveness of heparin?
Correct Answer: A
Rationale: The correct answer is A: PTT (Partial Thromboplastin Time). PTT measures the effectiveness of heparin therapy by assessing the clotting time. Monitoring PTT helps ensure the therapeutic range of heparin is maintained to prevent clot formation. Incorrect Choices: B: HCT (Hematocrit) - measures the percentage of red blood cells in the blood, not specific to heparin monitoring. C: CBC (Complete Blood Count) - provides overall information about blood cells, not specific to heparin monitoring. D: PT (Prothrombin Time) - used to monitor Warfarin therapy, not heparin.
Question 5 of 5
A client experiences acute myocardial ischemia. The nurse administers oxygen and sublingual nitroglycerin. When assessing an electrocardiogram (ECG) for evidence that blood flow to the myocardium has improved, the nurse should focus on the:
Correct Answer: C
Rationale: The correct answer is C: Return of the ST segment to baseline. This change indicates reperfusion of the myocardium, restoring blood flow and reducing ischemia. Widening of the QRS complex (A) suggests conduction abnormalities, not improved blood flow. Frequency of ectopic beats (B) can be a sign of ongoing myocardial damage. Presence of a significant Q wave (D) indicates a prior myocardial infarction, not immediate improvement in blood flow. Therefore, focusing on the return of the ST segment to baseline is crucial for assessing myocardial reperfusion.