the nurse is giving a client an iv bolus of heparin what is the most important nursing action
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Nursing Elites

ATI RN

Cardiovascular System Practice Exam

1. The nurse is giving a client an IV bolus of heparin. What is the most important nursing action?

Correct answer: A

Rationale: When administering an IV bolus of heparin, the most important nursing action is to monitor the client's heart rate. Heparin can cause bradycardia as a side effect, making it crucial to assess the heart rate for any abnormalities. Checking the blood pressure (Choice B) is important but not as critical as monitoring the heart rate. While checking for signs of bleeding (Choice C) is essential, it is not the most crucial action when administering heparin. Monitoring the respiratory rate (Choice D) is also important but not as directly related to the potential side effects of heparin as monitoring the heart rate.

2. The client is on nitroglycerin and reports chest pain. What is the nurse’s priority action?

Correct answer: D

Rationale: The correct answer is D: Notify the healthcare provider immediately. If a client on nitroglycerin reports chest pain, the priority action is to notify the healthcare provider immediately. This is crucial to ensure prompt reassessment of the client's condition and treatment plan. Administering nitroglycerin, morphine, or aspirin without consulting the healthcare provider first can be risky as the chest pain may indicate a need for a change in treatment or further evaluation. Administering medications without proper assessment and guidance can lead to complications and is not recommended in this scenario.

3. Which type of medication helps to reduce blood pressure by relaxing the blood vessels?

Correct answer: A

Rationale: The correct answer is A, Calcium channel blocker. Calcium channel blockers work by relaxing the blood vessels, making it easier for the heart to pump blood and reducing blood pressure. Choice B, ACE inhibitor, reduces blood pressure by blocking the production of angiotensin II, a substance that narrows blood vessels. Choice C, Beta-blocker, reduces heart rate and the heart's workload, not directly relaxing blood vessels. Choice D, Diuretic, reduces blood pressure by increasing urine output, reducing the volume of fluid in the blood vessels, rather than directly relaxing them.

4. What is a surgical procedure to replace a damaged or diseased heart valve with a prosthetic valve?

Correct answer: A

Rationale: Valve replacement is the correct answer because it involves replacing a damaged or diseased heart valve with a prosthetic valve. This procedure is essential for improving blood flow and heart function. Angioplasty (choice B) is a procedure to widen narrowed or obstructed arteries. Stent placement (choice C) involves inserting a mesh tube to help support weak arteries. Bypass surgery (choice D) is a procedure to create new routes for blood flow when arteries are blocked.

5. Which condition is characterized by the right ventricle of the heart failing due to increased pressure in the lungs, often caused by chronic lung disease?

Correct answer: A

Rationale: The correct answer is Cor pulmonale, a condition where the right ventricle of the heart fails due to increased pressure in the lungs, commonly caused by chronic lung diseases like COPD. Pulmonary embolism (choice B) is a blockage in one of the pulmonary arteries in the lungs, usually caused by a blood clot. Aortic stenosis (choice C) is a narrowing of the aortic valve opening that restricts blood flow from the left ventricle to the aorta. Hypertrophic cardiomyopathy (choice D) is a genetic condition where the heart muscle becomes abnormally thick, making it harder for the heart to pump blood.

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