ATI RN
Cardiovascular System Test Bank Questions
Question 1 of 5
To improve the physical activity level for a mildly obese 71-yr-old patient, which action should the nurse plan to take?
Correct Answer: B
Rationale: The correct answer is B: Determine what kind of physical activities the patient usually enjoys. Rationale: 1. By determining the patient's preferred physical activities, the nurse can tailor an exercise plan that the patient is more likely to adhere to. 2. Enjoyable activities increase motivation and compliance, leading to sustained physical activity levels. 3. Personalized approach considers the patient's interests and abilities, promoting a successful and sustainable exercise routine. Summary of Incorrect Choices: A. Stressing weight loss may be discouraging and overshadow the importance of overall health benefits of exercise. C. Setting a strict time limit may not be suitable for all older adults and can hinder individualized exercise plans. D. While warming up is important, it is not the most crucial initial step in developing a personalized exercise plan.
Question 2 of 5
A nurse administers warfarin (Coumadin) to a client with deep vein thrombophlebitis. Which laboratory valve indicates that the client has a therapeutic level of warfarin?
Correct Answer: C
Rationale: The correct answer is C: International Normalized Ratio (INR) of 3 to 4. For patients on warfarin therapy, INR is used to monitor the anticoagulant effect. An INR of 3 to 4 indicates a therapeutic level, reducing the risk of clot formation while minimizing the risk of bleeding. Rationale: 1. A: PTT measures intrinsic clotting pathway, not specific for warfarin monitoring. 2. B: PT measures extrinsic clotting pathway, not specific for warfarin monitoring. 3. D: HCT measures the percentage of red blood cells in blood, not related to warfarin monitoring. INR is the standard test for monitoring warfarin therapy, ensuring the effectiveness and safety of anticoagulation.
Question 3 of 5
An infant with a congenital cyanotic heart defect has a complete blood count drawn, revealing an elevated red blood cell (RBC) count. Which condition do these findings indicate?
Correct Answer: D
Rationale: The correct answer is D: Hypoxia compensation. In a cyanotic heart defect, there is decreased oxygenation, leading to hypoxia. The body compensates by increasing RBC production to improve oxygen-carrying capacity. Anemia (choice A) is a decrease in RBC count, not an increase. Dehydration (choice B) would typically lead to hemoconcentration but not specifically an elevated RBC count. Jaundice (choice C) is due to elevated bilirubin levels, unrelated to RBC count. Therefore, the elevated RBC count in this infant indicates a compensatory response to hypoxia, supporting choice D.
Question 4 of 5
A client undergoes ligation of varicose veins. The nurse includes in the plan of care which of the following important interventions for the nursing diagnosis of ineffective tissue perfusion?
Correct Answer: B
Rationale: Step 1: Flexing the lower extremities helps promote blood circulation and prevents blood clot formation post-vein ligation. Step 2: Increased movement aids in preventing stasis and promotes tissue perfusion. Step 3: Flexing exercises can prevent complications such as deep vein thrombosis. Step 4: Removing compression stockings, numbness, and brisk scrubbing do not directly address tissue perfusion or circulation issues.
Question 5 of 5
During the acute phase of rheumatic fever, which of the following is a priority action of the nurse?
Correct Answer: B
Rationale: The correct answer is B because during the acute phase of rheumatic fever, the priority action of the nurse is to assess for early signs of endocarditis due to the risk of developing heart valve damage. Endocarditis is a serious complication of rheumatic fever that can lead to further cardiac issues. Monitoring for signs such as new or changing heart murmurs, fever, and signs of embolization is crucial for early detection and intervention. Choice A is incorrect because although ambulation is important for overall health, it is not the priority during the acute phase of rheumatic fever. Choice C is also incorrect as maintaining hydration is essential, but it is not the priority over monitoring for endocarditis. Choice D is incorrect as managing pain with strong narcotic analgesics is not the priority action during the acute phase of rheumatic fever.