ATI RN
ATI Med Surg Cardiac Exam Questions
Extract:
Nurses' notes
A&O x 3. Skin cool, clammy, pale. Respirations labored at 30/min, shallow. Coarse crackles throughout bilateral lung fields. O2 saturation 88% on room air. Jugular vein distention (JVD) present bilaterally. Heart sounds moderate and regular, rate 98/min. BP 114/78 mm Hg. Temperature 87.8° C (99.9° F). Denies pain
Question 1 of 5
Complete the diagram by specifying what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
| Actions to take A. Recommend smoking cessation program B. Apply O2 at 6L/min C. Apply O2 at 2L/min D. Monitor respiratory rate |
| Potential conditions A. Spontaneous pneumothorax B. Exacerbation of copd C. Pneumonia D. Worsening of congestive heart failure |
| Parameters to monitor A. Respiratory rate B. Oxygen saturation C. WBC Count D. Temperature |
Correct Answer: D,E,G
Rationale: Worsening congestive heart failure is indicated by crackles, JVD, and low O2 saturation; oxygen and monitoring respiratory rate and O2 saturation are critical.
Extract:
Nurses notes
Client admitted with report of chest pain radiating to the left arm, sweating, shortness of breath, and epigastric discomfort. Client awake, alert, and oriented x3. Lung sounds clear bilaterally, 5152 heart sounds noted. All pulses palpable. Skin cool and diaphoretic to touch. Rates pain as 6 on a 0 to 10 pain scale. Pain described as sharp in the chest area with feelings of tightness and indigestion. Bowel sounds active in all 4 quadrants.
Question 2 of 5
Complete the diagram by specifying what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
| Chronic stable angina |
| Myocardial infarction |
| Ischemic stroke |
| Cardiogenic shock |
| Administer oxygen |
| Request for a prescription of aspirin 325 mg |
| Vital signs |
Correct Answer: B,E,F,G
Rationale: Myocardial infarction is suggested by radiating chest pain and diaphoresis; oxygen, aspirin, vital signs, and ECG monitoring are essential.
Extract:
Question 3 of 5
A client has undergone diagnostic testing and received a diagnosis of sinus bradycardia. Which interventions are most appropriate and should be included in the client's plan of care? (SELECT ALL THAT APPLY)
Correct Answer: C,D,E
Rationale: Prevention of falls is essential due to the risk of dizziness and syncope. Monitoring heart rate and rhythm ensures detection of worsening bradycardia or arrhythmias. Assessing for neurologic changes is critical as reduced cerebral perfusion can cause confusion or syncope.
Question 4 of 5
A nurse is caring for a client with heart failure who takes furosemide (Lasix) 20 mg daily at home and is receiving 40 mg of furosemide (Lasix) IV daily in the hospital. The nurse is aware that this patient is at risk for which electrolyte imbalance?
Correct Answer: C
Rationale: Furosemide, a loop diuretic, increases potassium excretion, leading to a risk of hypokalemia, which can cause muscle weakness and arrhythmias.
Question 5 of 5
A nurse is caring for a patient with a history of hypertension. The client reports compliance with the prescribed thiazide medication but is complaining of generalized weakness and palpitations. The nurse should monitor the client for which potential complications of diuretics?
Correct Answer: D
Rationale: Thiazide diuretics promote potassium loss, increasing the risk of hypokalemia, which can lead to cardiac dysrhythmias, palpitations, and weakness.