the client on a beta blocker has a blood pressure of 8858 mm hg what is the nurses priority action
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Nursing Elites

ATI RN

Cardiovascular System Exam

1. The client on a beta blocker has a blood pressure of 88/58 mm Hg. What is the nurse’s priority action?

Correct answer: A

Rationale: The correct action for the nurse to take when a client on a beta blocker presents with a blood pressure of 88/58 mm Hg is to hold the beta blocker and notify the healthcare provider. Beta blockers can further decrease blood pressure, which is already low in this case. Administering the beta blocker as ordered (Choice B) would exacerbate the hypotension. Increasing the dose of the beta blocker (Choice C) would be inappropriate and unsafe given the low blood pressure. Continuing to monitor the client and reassessing in 30 minutes (Choice D) could lead to a delay in necessary intervention. Therefore, the priority is to hold the medication and seek guidance from the healthcare provider.

2. What condition involves the heart's electrical system malfunctioning, causing very fast heartbeats originating from the ventricles?

Correct answer: A

Rationale: Ventricular tachycardia is the correct answer. It is a condition characterized by the heart's electrical system malfunctioning, leading to very fast heartbeats originating from the ventricles. Ventricular tachycardia can be life-threatening as it may progress to ventricular fibrillation, causing cardiac arrest. Atrial fibrillation (choice B) involves rapid, irregular beating of the atria, not the ventricles. Supraventricular tachycardia (choice C) originates above the ventricles and does not involve ventricular malfunction. Bradycardia (choice D) is the opposite of tachycardia, characterized by an abnormally slow heart rate.

3. The nurse is administering a beta blocker to a client with a heart rate of 58 bpm. What is the nurse’s priority action?

Correct answer: B

Rationale: The correct answer is B. A heart rate of 58 bpm is considered low, and beta blockers can further decrease the heart rate. Therefore, the nurse's priority action should be to hold the beta blocker and notify the healthcare provider for further assessment. Choice A is incorrect because administering the beta blocker without considering the low heart rate can worsen the condition. Choice C is incorrect as increasing the dose of the beta blocker can lead to further slowing of the heart rate, which is not safe in this situation. Choice D is not the priority action; holding the medication and seeking guidance from the healthcare provider is more crucial.

4. From where do these originate, behind the cusps of the aortic valve, in an area known as Valsalva’s sinus?

Correct answer: B

Rationale: The correct answer is B, Aortic valve. The aortic valve is a semilunar valve located between the left ventricle and the aorta. It prevents the backflow of blood from the aorta into the left ventricle. The pulmonary valve (choice A) is located between the right ventricle and the pulmonary artery, not in the Valsalva’s sinus area. The tricuspid valve (choice C) is situated between the right atrium and right ventricle, and the mitral valve (choice D) is located between the left atrium and left ventricle, making them incorrect choices for this question.

5. Which test measures how much and how quickly you can move air out of your lungs?

Correct answer: A

Rationale: The correct answer is A, Spirometry. Spirometry is a common pulmonary function test that measures lung function by assessing the amount (volume) and speed (flow) of air that can be inhaled and exhaled. This test helps in diagnosing conditions like asthma, chronic obstructive pulmonary disease (COPD), and other lung diseases. Peak flow meter (choice B) measures the maximum speed at which a person can exhale air, mainly used in asthma management. Lung volume test (choice C) evaluates the total amount of air the lungs can hold. Arterial blood gas (choice D) measures the levels of oxygen and carbon dioxide in the blood, providing information on how well the lungs are functioning in gas exchange, but it does not specifically measure the amount and speed of air movement in and out of the lungs like spirometry does.

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