ATI RN
ATI Nur 221 Med Surg Exam Cardiac Questions
Extract:
Vital Signs
Diagnostic Results
Nurses Notes
Temperature 37.2° C (98.9° F)
Heart rate 138/min
Respiratory rate 28/min
Blood pressure 96/75 mm Hg
Oxygen saturation 93%
Question 1 of 5
A nurse is admitting a client who has a history of heart failure. Check the 5 findings that require immediate follow-up.
| Vital signs |
| Respiratory assessment |
| Renal function |
| Cardiac enzymes |
| BNP |
| ECG results |
| Neurologic status |
Correct Answer: A,B,C,E,F
Rationale: Vital signs (
A), respiratory assessment (
B), renal function (
C), BNP (E), and ECG results (F) require immediate follow-up due to tachycardia, tachypnea, possible pulmonary edema, kidney impairment, and atrial fibrillation. Cardiac enzymes and neurologic status are less urgent.
Extract:
Question 2 of 5
A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first?
Correct Answer: C
Rationale: Administering oxygen therapy is correct. A pulmonary embolism impairs oxygenation, and immediate oxygen administration improves delivery to vital organs. Morphine, cardiac monitoring, and IV fluids are secondary priorities.
Question 3 of 5
A nurse is planning care for a client who has quadriplegia. Which of the following actions should the nurse take to prevent a pulmonary embolism (PE)? (Select all that apply.)
Correct Answer: B,C,D
Rationale: Applying elastic compression stockings (
B), performing passive range of motion exercises (
C), and assessing legs for redness (
D) are correct. These actions promote venous return, prevent stasis, and allow early detection of DVT, reducing PE risk. Massaging calves (
A) can dislodge clots, and pillows under knees (E) impair circulation, increasing clot risk.
Question 4 of 5
The nurse is providing care for a client admitted to rule out a myocardial infarction who is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first?
Correct Answer: B
Rationale: Having the client sit down immediately is correct. Stopping activity reduces cardiac workload and oxygen demand, preventing further ischemia. Obtaining an ECG, assessing vital signs, and administering nitroglycerin are subsequent actions.
Question 5 of 5
What is the underlying rationale for why a nurse assesses a client with emphysema for clinical indicators of hypoxia?
Correct Answer: C
Rationale: Lack of adequate surface area for aeration is correct. Emphysema causes alveolar destruction, reducing gas exchange surface area, leading to chronic hypoxia. Mucus production, infections, and bronchiole inflammation are more relevant to chronic bronchitis or other conditions.