ATI RN
Cardiovascular System Practice Exam Questions
Question 1 of 5
The nurse is giving a client an IV bolus of heparin. What is the most important nursing action?
Correct Answer: A
Rationale: The correct answer is A: Monitor the client's heart rate. When administering an IV bolus of heparin, it is crucial to monitor the client's heart rate because heparin can cause serious side effects such as bleeding and heparin-induced thrombocytopenia, which can lead to changes in heart rate. Checking blood pressure (B) is also important but not as critical as monitoring heart rate. Checking for signs of bleeding (C) is necessary but should be done after monitoring the heart rate. Monitoring the client's respiratory rate (D) is not directly related to heparin administration.
Question 2 of 5
The nurse is administering an ACE inhibitor to a client. What is the most common side effect?
Correct Answer: A
Rationale: The correct answer is A: Cough. ACE inhibitors commonly cause a persistent dry cough due to the accumulation of bradykinin. This side effect occurs in up to 20% of patients. Dizziness (B) and hypotension (C) are potential side effects of ACE inhibitors but not as common as cough. Hyperkalemia (D) can occur with ACE inhibitors but is not the most common side effect.
Question 3 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 4 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 5 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.