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 could indicate impaired circulation to the right hand due to a complication related to the radial artery graft. Impaired circulation could lead to ischemia or even graft failure, which are serious concerns post coronary artery bypass grafting. This information is crucial to communicate to the health care provider for immediate intervention to prevent further complications. Incorrect choices: A: Complaints of incisional chest pain - While chest pain is important to monitor post-surgery, it is a common occurrence and may not indicate a serious complication. C: Fine crackles heard at both lung bases - This finding may suggest fluid overload or pulmonary issues, but it is not directly related to the radial artery graft or its complications. D: Redness on both sides of the sternal incision - Redness at the incision site can be a sign of infection, but it is not as urgent as the potential circulation issue in the right hand, which could
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 commonly presents with dyspnea due to fluid accumulation in the lungs (pulmonary edema). This occurs because the weakened left ventricle cannot efficiently pump blood to the body, causing fluid to back up into the lungs. Ascites (A) is more commonly associated with right-sided heart failure. Hepatomegaly (C) and jugular vein distention (D) are signs of right-sided heart failure, not left-sided heart failure. Dyspnea is a hallmark symptom of left-sided heart failure due to pulmonary congestion.
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. 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 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 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 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: 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.