ATI RN
ATI Nur 221 Med Surg Exam Cardiac Questions
Extract:
Question 1 of 5
A nurse is assessing a client with the diagnosis of left-sided heart failure. Which clinical finding should the nurse expect the client to experience?
Correct Answer: A
Rationale: Orthopnea is correct. Left-sided heart failure causes pulmonary congestion, leading to difficulty breathing when lying flat. Bradycardia, diaphoresis, and yellow sputum are not hallmark symptoms of left-sided heart failure.
Question 2 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 3 of 5
The nurse is providing care to a client with a suspected pulmonary embolism. Which of the following is not a manifestation of a pulmonary embolism?
Correct Answer: D
Rationale: Facial weakness is not a typical sign of pulmonary embolism. Hemoptysis, tachycardia, and even petechiae (in rare cases like fat embolism) can be associated, but facial weakness is more indicative of stroke or Bell's palsy.
Question 4 of 5
The nurse and unlicensed assistive personnel (UAP) are caring for an elderly client diagnosed with emphysema. Which nursing tasks could be delegated to the UAP to improve gas exchange? (Select All that Apply)
Correct Answer: C,D,E
Rationale: Encouraging deep breathing exercises (
C), recording pulse oximeter readings (
D), and keeping the head of bed elevated (E) can be delegated to a UAP to improve gas exchange. Assessing consciousness and auscultating breath sounds require nursing judgment.
Question 5 of 5
The nurse is providing education to a client on ways to prevent the development of a pulmonary embolism. Which of the following statements would require further teaching?
Correct Answer: A
Rationale: Crossing the legs increases the risk of venous stasis and clot formation, requiring further teaching. Quitting smoking, staying hydrated, and exercising are appropriate preventive measures.