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. Which condition is caused by a bacterium that primarily affects the lungs but can spread to other parts of the body?
- A. Tuberculosis
- B. Pneumonia
- C. Legionnaires' disease
- D. Histoplasmosis
Correct answer: A
Rationale: The correct answer is A, Tuberculosis. Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis, primarily affecting the lungs but can spread to other organs. Choice B, Pneumonia, is an infection that inflames the air sacs in one or both lungs. Choice C, Legionnaires' disease, is a severe form of pneumonia caused by the Legionella bacteria. Choice D, Histoplasmosis, is a fungal infection caused by inhaling spores of the Histoplasma capsulatum fungus.
3. Which test measures how well the lungs work by assessing the amount of air the lungs can hold and how quickly air can be exhaled?
- A. Spirometry
- B. Pulse oximetry
- C. Arterial blood gas (ABG)
- D. Chest X-ray
Correct answer: A
Rationale: The correct answer is A, Spirometry. Spirometry is a pulmonary function test that evaluates lung function by measuring the amount of air a person can exhale and how quickly, assisting in the diagnosis of conditions such as asthma and COPD. Choices B, C, and D are incorrect because Pulse oximetry measures oxygen saturation in the blood, Arterial blood gas (ABG) evaluates blood pH, oxygen, and carbon dioxide levels, and a Chest X-ray provides an image of the lungs but does not measure lung function.
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. The client is being taught about the use of warfarin. What is the most important dietary instruction?
- A. Avoid foods high in vitamin K.
- B. Increase the intake of vitamin K-rich foods.
- C. Avoid foods high in protein.
- D. Increase the intake of foods high in calcium.
Correct answer: A
Rationale: The correct answer is A: Avoid foods high in vitamin K. Warfarin is a medication that works by decreasing the activity of vitamin K in the body to prevent blood clotting. Therefore, consuming foods high in vitamin K like green leafy vegetables can interfere with the medication's effectiveness. Choices B, C, and D are incorrect. Increasing the intake of vitamin K-rich foods would counteract the effects of warfarin. Avoiding foods high in protein or increasing the intake of foods high in calcium are not specifically related to the use of warfarin.
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