ATI Cardiac Content Practice Assessment: Key
Nursing Concepts A Series Of Questions And
Correct Answers With Verified Solution.
You are reviewing the chart of a PT who is receiving heparin therapy for a DVT.
Which intervention should the RN anticipate taking if the PTs aPTT is 96 seconds?
1. Increase heparin infusion rate by 2mL/hr
2. Continue monitor the heparin infusion as prescribed
3. Request a prothrombin time PT
4. Stop the heparin infusion - ANSWER: 4. Stop the heparin infusion- pt is above
the therapeutic range of 1-5-2 times the control. should discontinue to prevent harm
You are providing teaching to a PT who is 2 days post op following a heart
transplant. Which following statements should the nurse include in the teaching?
1. You may no longer be able to feel chest pain
2. Your level of activity intolerance will not change
3. after 6 months you will no longer need to restrict you Na
4. You will be able to stop taking immunosuppressants after 12 months -
ANSWER: 1. You may no longer be able to feel chest pain- transplant PTs no
longer feel chest pain due to denervation of the heart
ER nurse is assessing PT with bradydysrhythmia. Which finding should he expect?
1. Confusion
2. Friction Rub
3. HTN
4. Dry skin - ANSWER: 1. Confusion- as a result of decreased tissue perfusion
You are caring for a PT who had an anterior MI. PTs hx shows she is 1 wk post op
open cholecystectomy the RN knows that which intervention is contraindicated?
,1. Administering IV morphine
2. giving O2 at 2L NC
3. Helping client to BSC
4. Assisting in thrombolytic therapy - ANSWER: 4. Assisting in thrombolytic
therapy- having surgery within 3 wks is a contraindication for thrombolytic therapy
You are caring for a PT who has endocarditis. Which finding should you recognize
as a complication?
1. Ventricular depolarization
2. Guillain Barre Syndrome
3. Myelodysplastic syndrome
4. Valvular disease - ANSWER: 4. Valvular disease- damage will occur as a result
of inflammation or infection of the endocardium
You are caring for PT with BP of 254/139, you recognize the PT is in a hypertensive
crisis. Which action should you take first?
1. Obtain blood samples for testing
2. Tell the PT to report vision changes
3. Place HOB at 45 degrees
4. Initiate IV access - ANSWER: 3. Place HOB at 45 degrees-ABC's this will
promote respiratory status and promote venous return reducing workload on heart
**Initiate IV access- not first action
When performing a cardiac assessment what is the point of maximal impulse?
1. 2nd intercostal space right to the sternum
2. 2nd intercostal space left to the sternum
3. 5th intercostal space to the left of thermal border
, 4. Left 5th intercostal space in the midclavicular line - ANSWER: 4. Left 5th
intercostal space in the midclavicular line-this is best to hear the apex of the heart
which is considered maximal impulse
You are caring for a PT who is experiencing Afib. You should report what finding to
the provider?
1. Slurred speech
2. Irregular pulse
3. Dependent edema
4. Persistant fatigue - ANSWER: 1. Slurred speech- greatest risk is an embolus
and this can indicate embolus
You are assessing a PT with Left sided heart failure. What manifestation should you
expect to find?
1. Increased abdominal girth
2. Weak peripheral pulses
3. Jugular venous neck distention
4. Dependent edema - ANSWER: 2. Weak peripheral pulses- r/t decreased CO
from LSHF
You are caring for a PT who is being treated for HF and has prescriptions for digoxin
and furosemide. You plan to monitor for which of the following as an adverse effect
of these meds?
1. SOB
2. Lightheadedness
3. Dry cough
4. Metallic taste - ANSWER: 2. Lightheadedness- can cause a sudden drop in
BP= lightheadedness
You are monitoring a PT following coronary bypass graft surgery (CABG). Which
finding indicates cardiac tamponade?
Nursing Concepts A Series Of Questions And
Correct Answers With Verified Solution.
You are reviewing the chart of a PT who is receiving heparin therapy for a DVT.
Which intervention should the RN anticipate taking if the PTs aPTT is 96 seconds?
1. Increase heparin infusion rate by 2mL/hr
2. Continue monitor the heparin infusion as prescribed
3. Request a prothrombin time PT
4. Stop the heparin infusion - ANSWER: 4. Stop the heparin infusion- pt is above
the therapeutic range of 1-5-2 times the control. should discontinue to prevent harm
You are providing teaching to a PT who is 2 days post op following a heart
transplant. Which following statements should the nurse include in the teaching?
1. You may no longer be able to feel chest pain
2. Your level of activity intolerance will not change
3. after 6 months you will no longer need to restrict you Na
4. You will be able to stop taking immunosuppressants after 12 months -
ANSWER: 1. You may no longer be able to feel chest pain- transplant PTs no
longer feel chest pain due to denervation of the heart
ER nurse is assessing PT with bradydysrhythmia. Which finding should he expect?
1. Confusion
2. Friction Rub
3. HTN
4. Dry skin - ANSWER: 1. Confusion- as a result of decreased tissue perfusion
You are caring for a PT who had an anterior MI. PTs hx shows she is 1 wk post op
open cholecystectomy the RN knows that which intervention is contraindicated?
,1. Administering IV morphine
2. giving O2 at 2L NC
3. Helping client to BSC
4. Assisting in thrombolytic therapy - ANSWER: 4. Assisting in thrombolytic
therapy- having surgery within 3 wks is a contraindication for thrombolytic therapy
You are caring for a PT who has endocarditis. Which finding should you recognize
as a complication?
1. Ventricular depolarization
2. Guillain Barre Syndrome
3. Myelodysplastic syndrome
4. Valvular disease - ANSWER: 4. Valvular disease- damage will occur as a result
of inflammation or infection of the endocardium
You are caring for PT with BP of 254/139, you recognize the PT is in a hypertensive
crisis. Which action should you take first?
1. Obtain blood samples for testing
2. Tell the PT to report vision changes
3. Place HOB at 45 degrees
4. Initiate IV access - ANSWER: 3. Place HOB at 45 degrees-ABC's this will
promote respiratory status and promote venous return reducing workload on heart
**Initiate IV access- not first action
When performing a cardiac assessment what is the point of maximal impulse?
1. 2nd intercostal space right to the sternum
2. 2nd intercostal space left to the sternum
3. 5th intercostal space to the left of thermal border
, 4. Left 5th intercostal space in the midclavicular line - ANSWER: 4. Left 5th
intercostal space in the midclavicular line-this is best to hear the apex of the heart
which is considered maximal impulse
You are caring for a PT who is experiencing Afib. You should report what finding to
the provider?
1. Slurred speech
2. Irregular pulse
3. Dependent edema
4. Persistant fatigue - ANSWER: 1. Slurred speech- greatest risk is an embolus
and this can indicate embolus
You are assessing a PT with Left sided heart failure. What manifestation should you
expect to find?
1. Increased abdominal girth
2. Weak peripheral pulses
3. Jugular venous neck distention
4. Dependent edema - ANSWER: 2. Weak peripheral pulses- r/t decreased CO
from LSHF
You are caring for a PT who is being treated for HF and has prescriptions for digoxin
and furosemide. You plan to monitor for which of the following as an adverse effect
of these meds?
1. SOB
2. Lightheadedness
3. Dry cough
4. Metallic taste - ANSWER: 2. Lightheadedness- can cause a sudden drop in
BP= lightheadedness
You are monitoring a PT following coronary bypass graft surgery (CABG). Which
finding indicates cardiac tamponade?
