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: To improve physical activity for a mildly obese 71-yr-old patient, the nurse should determine what physical activities the patient enjoys. This approach considers the patient's preferences, increasing the likelihood of adherence. Stressing weight loss (A) may not be motivating for everyone. Limiting exercise time (C) is not evidence-based. A warm-up (D) is important but not the initial step.
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. INR is the standard measurement of the time it takes for blood to clot. For clients on warfarin therapy, a therapeutic INR range is typically between 2 to 3 for most indications. However, in the case of deep vein thrombophlebitis, a slightly higher range of 3 to 4 is often targeted. This range ensures adequate anticoagulation to prevent clot formation without increasing the risk of bleeding excessively. Now, let's analyze why the other choices are incorrect: A: Partial thromboplastin time (PTT) is used to monitor heparin therapy, not warfarin. B: Prothrombin time (PT) is used to monitor warfarin therapy, but the correct therapeutic range is typically 1.5 to 2.5 times the control, not 1.5 to 2 times. D
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 elevated RBC count in an infant with a congenital cyanotic heart defect indicates the body's response to chronic hypoxia by producing more RBCs to compensate for decreased oxygen levels. This is known as hypoxia compensation. Anemia (choice A) is characterized by decreased RBC count, dehydration (choice B) does not typically cause elevated RBC count, and jaundice (choice C) is related to liver function and bilirubin levels, not RBC count.
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: Rationale for Choice B (Correct Answer): Flexing lower extremities four times a day helps promote circulation and prevent blood stasis, aiding in tissue perfusion after vein ligation. Rationale for why other choices are incorrect: A: Removing compression stockings can hinder venous return and worsen tissue perfusion. C: Numbness is not a normal finding post-vein ligation and should be promptly reported. D: Briskly scrubbing lower extremities can damage the skin and impair circulation, worsening tissue perfusion.
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: Assess for early signs of endocarditis. During the acute phase of rheumatic fever, endocarditis can develop as a complication due to the inflammation and damage to the heart valves. Early detection of endocarditis is crucial to prevent serious complications. By assessing for early signs such as new or changing heart murmurs, fever, fatigue, and shortness of breath, the nurse can promptly intervene and prevent further damage to the heart valves. Encouraging ambulation, maintaining hydration, and managing pain are important aspects of care but assessing for endocarditis takes precedence due to its potential impact on the patient's health and outcomes.