ATI RN
Physical Exam Cardiovascular System
1. What is a severe and often sudden allergic reaction that can lead to breathing difficulties and anaphylactic shock?
- A. Anaphylaxis
- B. Allergic rhinitis
- C. Bronchospasm
- D. Asthma attack
Correct answer: A
Rationale: Anaphylaxis is the correct answer. It is a severe allergic reaction that can result in difficulty breathing, a drop in blood pressure, and even anaphylactic shock if not treated promptly. Choice B, allergic rhinitis, is characterized by symptoms such as a runny or stuffy nose, sneezing, and itching. Choice C, bronchospasm, refers to the sudden constriction of the muscles in the walls of the bronchioles, leading to breathing difficulties. Choice D, asthma attack, involves the inflammation and narrowing of the airways, resulting in symptoms like wheezing, coughing, and chest tightness.
2. The nurse is teaching a client about side effects of ACE inhibitors. What is the most important side effect to monitor?
- A. Cough
- B. Hyperkalemia
- C. Hypotension
- D. Dizziness
Correct answer: A
Rationale: The correct answer is A: Cough. ACE inhibitors commonly cause a persistent dry cough in patients. This side effect is important to monitor because it can indicate the development of angioedema, a serious adverse reaction that requires immediate medical attention. Hyperkalemia (choice B) is a potential side effect of ACE inhibitors but is not typically the most important one to monitor. Hypotension (choice C) and dizziness (choice D) are also possible side effects of ACE inhibitors, but they are not as critical to monitor as the development of a persistent cough.
3. The client is receiving digoxin and has a potassium level of 2.8 mEq/L. What is the nurse’s priority action?
- A. Hold the digoxin and notify the healthcare provider.
- B. Increase the dose of digoxin.
- C. Continue the current dose of digoxin.
- D. Administer potassium supplements.
Correct answer: A
Rationale: The correct answer is to hold the digoxin and notify the healthcare provider. A potassium level of 2.8 mEq/L indicates hypokalemia, which can increase the risk of digoxin toxicity. Holding the medication and informing the healthcare provider is crucial to prevent adverse effects. Choice B is incorrect because increasing the dose of digoxin would further raise the risk of toxicity. Choice C is incorrect as continuing the current dose could exacerbate the toxicity risk. Choice D is incorrect because administering potassium supplements alone is not sufficient to address the potential digoxin toxicity; the first step should be to hold the digoxin and seek further guidance.
4. Which heart chamber receives oxygenated blood from the four pulmonary veins and serves as a reservoir during ventricular systole?
- A. Right atrium
- B. Left atrium
- C. Right ventricle
- D. Left ventricle
Correct answer: B
Rationale: The correct answer is B, Left atrium. The left atrium receives oxygenated blood from the lungs via the four pulmonary veins and acts as a holding chamber before the blood is pumped into the left ventricle. Choice A, Right atrium, is incorrect as it receives deoxygenated blood from the body via the vena cava. Choices C and D, Right ventricle and Left ventricle, are incorrect as they receive blood from the atria, not the pulmonary veins.
5. The client is on spironolactone (Aldactone). What is the most important dietary instruction?
- A. Avoid foods high in potassium.
- B. Increase intake of foods high in potassium.
- C. Avoid foods high in sodium.
- D. Increase intake of foods high in sodium.
Correct answer: A
Rationale: The correct answer is to avoid foods high in potassium. Spironolactone is a potassium-sparing diuretic, meaning it helps the body retain potassium and can lead to hyperkalemia if too much potassium is consumed. Choices B, C, and D are incorrect because increasing intake of potassium-rich foods can worsen hyperkalemia, while avoiding foods high in sodium is not the primary concern when taking spironolactone.
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