ATI RN
Physical Exam Cardiovascular System
1. What is a condition where the heart's valves do not function properly, leading to disrupted blood flow within the heart?
- A. Valvular heart disease
- B. Myocarditis
- C. Endocarditis
- D. Aneurysm
Correct answer: A
Rationale: Valvular heart disease is the correct answer. It occurs when the heart's valves malfunction, leading to disrupted blood flow within the heart. Myocarditis refers to inflammation of the heart muscle, not specifically related to valve function. Endocarditis is an infection of the inner lining of the heart chambers and valves, not necessarily caused by valve malfunction. Aneurysm is the abnormal bulging of a blood vessel, not directly related to heart valve function.
2. What is a condition where the heart beats too slowly, reducing the amount of blood pumped to the body?
- A. Bradycardia
- B. Tachycardia
- C. Atrial fibrillation
- D. Ventricular fibrillation
Correct answer: A
Rationale: Bradycardia is the correct answer. It is a condition characterized by a slow heart rate, which reduces the amount of blood pumped to the body. This can lead to symptoms like fatigue and dizziness. Choice B, Tachycardia, is the opposite condition where the heart beats too fast. Choices C and D, Atrial fibrillation and Ventricular fibrillation, refer to irregular and potentially life-threatening rapid heart rhythms involving the atria and ventricles respectively, not a slow heart rate.
3. This is the inflammation of the heart's inner lining, usually caused by an infection.
- A. Endocarditis
- B. Myocarditis
- C. Pericarditis
- D. Valvulitis
Correct answer: A
Rationale: Endocarditis is the inflammation of the inner lining of the heart's chambers and valves, usually caused by a bacterial infection. Myocarditis is the inflammation of the heart muscle, Pericarditis is the inflammation of the pericardium (the outer lining of the heart), and Valvulitis is the inflammation of the heart valves. Therefore, in this case, the correct answer is Endocarditis as it specifically refers to the inflammation of the heart's inner lining.
4. The client on warfarin has an INR of 5.5. What is the priority nursing action?
- A. Administer vitamin K as an antidote.
- B. Hold the next dose of warfarin.
- C. Increase the dose of warfarin.
- D. Administer fresh frozen plasma.
Correct answer: A
Rationale: An INR of 5.5 is significantly elevated, indicating an increased risk of bleeding. The priority nursing action in this situation is to administer vitamin K as an antidote to reverse the effects of warfarin and lower the INR. Holding the next dose of warfarin (choice B) is important but not as immediate as administering vitamin K. Increasing the dose of warfarin (choice C) would further elevate the INR, worsening the bleeding risk. Administering fresh frozen plasma (choice D) is not the first-line treatment for high INR due to warfarin.
5. The nurse is teaching a client about the side effects of beta blockers. What is the most important side effect to monitor?
- A. Hypotension
- B. Bradycardia
- C. Hyperkalemia
- D. Tachycardia
Correct answer: A
Rationale: The most important side effect to monitor when a client is on beta blockers is hypotension. Beta blockers can cause a significant drop in blood pressure, especially at the initiation of therapy. Monitoring for hypotension is crucial to prevent complications such as dizziness, syncope, or falls. While bradycardia can also occur with beta blockers, hypotension takes precedence due to its immediate impact on perfusion. Hyperkalemia is not a common side effect of beta blockers. Tachycardia is actually a condition that beta blockers aim to treat, so it is not a side effect to monitor.
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