ATI RN
Cardiovascular System Test Bank Questions
Question 1 of 5
Which assessment finding by the nurse caring for a patient who has had coronary artery bypass grafting using a right radial artery graft is most important to communicate to the health care provider?
Correct Answer: B
Rationale: The correct answer is B: Pallor and weakness of the right hand. This finding suggests potential compromise of blood flow to the right radial artery graft, which is crucial for the patient's cardiac function. Pallor and weakness may indicate reduced perfusion, possibly due to graft occlusion or other complications. This warrants immediate attention from the healthcare provider to prevent further complications. Incorrect choices: A: Complaints of incisional chest pain - This is common post-surgery and may not indicate acute issues with the graft. C: Fine crackles heard at both lung bases - This could indicate a respiratory issue, but it is not directly related to the radial artery graft. D: Redness on both sides of the sternal incision - While redness could suggest infection, it is not as urgent as compromised blood flow to the graft, which requires immediate intervention.
Question 2 of 5
A nurse is evaluating a client with left- sided heart failure. Which finding should the nurse expect to assess?
Correct Answer: B
Rationale: The correct answer is B: Dyspnea. Left-sided heart failure typically results in the accumulation of fluid in the lungs, leading to difficulty breathing or dyspnea. This is due to the impaired ability of the left side of the heart to pump blood efficiently, causing fluid backup into the lungs. Ascites (choice A) is more commonly associated with right-sided heart failure. Hepatomegaly (choice C) and jugular vein distention (choice D) are also more indicative of right-sided heart failure. Therefore, based on the pathophysiology of left-sided heart failure, dyspnea is the expected finding.
Question 3 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 4 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 5 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.