ATI RN
Physical Exam Cardiovascular System
1. The client on nitroglycerin complains of a headache. How does the nurse explain this?
- A. This is a normal side effect of nitroglycerin.
- B. This is an allergic reaction to nitroglycerin.
- C. This is an indication of overdose.
- D. This is a sign of heart failure.
Correct answer: A
Rationale: The correct answer is A: 'This is a normal side effect of nitroglycerin.' Headaches are a common side effect of nitroglycerin due to vasodilation. Choice B is incorrect because allergic reactions to nitroglycerin typically present with symptoms like rash, itching, or shortness of breath. Choice C is incorrect as an overdose of nitroglycerin would likely present with symptoms beyond just a headache. Choice D is incorrect because headaches related to nitroglycerin are not indicative of heart failure.
2. Which neurotransmitter released by the parasympathetic nervous system can decrease heart rate?
- A. Acetylcholine
- B. Norepinephrine
- C. Dopamine
- D. Serotonin
Correct answer: A
Rationale: Acetylcholine is the correct answer. It is a neurotransmitter released by the parasympathetic nervous system that can decrease heart rate. Norepinephrine, dopamine, and serotonin are neurotransmitters that usually have different effects on the body and are not specifically associated with decreasing heart rate. Norepinephrine, for example, is often related to the fight-or-flight response and can increase heart rate.
3. Which condition is characterized by chronic inflammation of the airways resulting in excess mucus production, leading to frequent coughing and breathing difficulties?
- A. Chronic bronchitis
- B. Asthma
- C. Pneumonia
- D. COPD
Correct answer: A
Rationale: The correct answer is A, Chronic bronchitis. Chronic bronchitis involves long-term inflammation of the bronchi, leading to excessive mucus production, frequent coughing, and breathing difficulties. Asthma (B) is characterized by reversible airway obstruction and bronchospasms. Pneumonia (C) is an infection of the lungs caused by bacteria, viruses, or fungi. COPD (D) is a term used to describe chronic lung diseases that cause airflow blockage and breathing-related problems.
4. The client on spironolactone (Aldactone) has a potassium level of 5.6 mEq/L. What is the nurse’s priority action?
- A. Hold the spironolactone and notify the healthcare provider.
- B. Administer potassium supplements.
- C. Continue the spironolactone as ordered.
- D. Increase the dose of spironolactone.
Correct answer: A
Rationale: The correct answer is A: Hold the spironolactone and notify the healthcare provider. A potassium level of 5.6 mEq/L is high, indicating hyperkalemia. Spironolactone is a potassium-sparing diuretic that can further elevate potassium levels. Therefore, the priority action is to withhold the medication to prevent exacerbating hyperkalemia and notify the healthcare provider for further management. Option B is incorrect because administering potassium supplements would worsen the hyperkalemia. Option C is incorrect as continuing spironolactone can lead to a further increase in potassium levels. Option D is incorrect as increasing the dose of spironolactone would be inappropriate in the presence of elevated potassium levels.
5. What is a condition where the lung's alveoli are permanently enlarged and damaged, leading to shortness of breath?
- A. Emphysema
- B. Bronchitis
- C. Atelectasis
- D. Pulmonary fibrosis
Correct answer: A
Rationale: Emphysema is the correct answer. It is a chronic lung condition characterized by the permanent enlargement and damage of the alveoli, leading to shortness of breath and impaired oxygen exchange. Bronchitis is the inflammation of the bronchial tubes, not specifically related to alveolar damage. Atelectasis is the collapse of lung tissue, not enlargement. Pulmonary fibrosis involves scarring and thickening of lung tissue, different from the alveolar damage seen in emphysema.
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