ATI MEDICAL SURGICAL CARDIOVASCULAR
EXAM | ALL QUESTIONS AND CORRECT
DETAILED ANSWERS | GRADED A+ | VERIFIED
ANSWERS | LATEST VERSION
A nurse is checking for cardiac tamponade on a client who has pericarditis.
What action should the nurse take? ---------CORRECT ANSWER--------------
---Auscultate blood pressure for pulsus paradoxus - The client who has
cardiac tamponade will have pulsus paradoxus when the systolic blood
pressure is at least 10 mm Hg higher on expiration than on inspiration. This
occurs because of the sudden decrease in cardiac output from the fluid
compressing the atria and ventricles.
A nurse is caring for a client who had a myocardial infarction 5 days ago.
The client has a sudden onset of shortness of breath and begins coughing
frothy, pink sputum. The nurse auscultates loud, bubbly sounds on
inspiration. What adventitious breath sounds should the nurse document? -
--------CORRECT ANSWER-----------------Coarse crackles - A client who had
a recent myocardial infarction is at risk for left-sided heart failure. Crackles
are breath sounds caused by movement of air through airways partially or
intermittently occluded with fluid and are associated with heart failure and
frothy sputum. Crackling sounds are heard at the end of inspiration and are
not cleared by coughing.
A nurse is evaluating a client's repeat laboratory results 4 hr after
administering fresh frozen plasma (FFP). What laboratory values should
the nurse review? ---------CORRECT ANSWER-----------------Prothrombin
time - The nurse should review the client's prothrombin time after the
administration of FFP, which is plasma rich in clotting factors. FFP is
administered to treat acute clotting disorders. The desired effect is a
decrease in the prothrombin time.
,A nurse is assisting in the plan of care for a client who is having a
percutaneous transluminal coronary angioplasty (PTCA) with stent
placement. What action should the nurse anticipate in the postoperative
plan of care? ---------CORRECT ANSWER-----------------Initiate an aspirin
regimen - The nurse should plan to initiate an aspirin regimen or another
antiplatelet agent. The antiplatelet medication maintains the patency of the
stent by reducing platelet aggregation.
A nurse is collecting data from a client who has pericarditis. What
manifestations should the nurse expect? ---------CORRECT ANSWER-------
----------Dyspnea - The client who has pericarditis will experience dyspnea,
hiccups, and a nonproductive cough. These manifestations can indicate
heart failure from pericardial compression due to constrictive pericarditis or
cardiac tamponade.
A nurse is assisting in the preparation of a unit of packed red blood cells
(RBCs) for a client who has anemia. What action should the nurse take
first? ---------CORRECT ANSWER-----------------Witness the informed
consent - The nurse should apply the least invasive priority-setting
framework. This framework assigns priority to nursing interventions that are
least invasive to the client, as long as those interventions do not jeopardize
client safety. The nurse should take interventions that are not invasive to
the client before interventions that are invasive; therefore, as witnessing the
informed consent is the least invasive it is the action that should be
performed first. Unless it is an emergency, informed consent should be
obtained prior to initiating a blood transfusion on a client.
A nurse is collecting data from a client who has fluid volume overload
resulting from a cardiovascular disorder. What manifestations should the
nurse expect? ---------CORRECT ANSWER-----------------Jugular vein
distension - The increase in venous pressure due to excessive circulating
blood volume results in neck vein distension.
,Moist crackles - This is an indicator of pulmonary edema that can quickly
lead to death.
Increased heart rate - Fluid volume excess, or hypervolemia, is an
expansion of fluid volume in the extracellular fluid compartment. This
results in increased heart rate and bounding pulses.
A nurse is assisting in developing the plan of care for an older adult client
who is to receive a unit of placed red blood cells (RBCs). What action
should the nurse recommend? ---------CORRECT ANSWER-----------------
Verify the information on the packed RBCs with another nurse - The nurse
should verify the information on the label of the packed RBCs with another
nurse. She should also verify the information on the label with the
provider's order, the blood administration form from the blood bank, and
with the client armband and blood bracelet.
A nurse is caring for a client who has hemophilia. The client reports pain
and swelling in a joint following an injury. What action should the nurse
take? ---------CORRECT ANSWER-----------------Prepare for replacement of
the missing clotting factor - Hemophilia is a hereditary bleeding disorder in
which blood clots slowly and abnormal bleeding occurs. It is caused by a
deficiency in the most common clotting factor, factor VIII (hemophilia A).
Aggressive factor replacement is initiated to prevent hemarthrosis that can
result in long-term loss of range-of-motion in repeatedly affected joints.
A nurse is administering a loop diuretic to a client who has 3+ pitting
edema in the lower extremities. What actions should the nurse take? --------
-CORRECT ANSWER-----------------Monitor the client for ototoxicity - The
nurse should monitor the client for ototoxicity and reinforce that the client
should report any manifestations of hearing impairment while on the loop
diuretic. The nurse should use caution when a loop diuretic is used in
conjunction with other ototoxic medications, such as aminoglycoside
antibiotics.
, A nurse is reinforcing teaching about lifestyle changes with a client who
had a myocardial infection and has a new prescription for a beta blocker.
What statement by the client indicates an understanding of the teaching? --
-------CORRECT ANSWER-----------------"Before taking my medication, I will
check my blood pressure and radial pulse rate." - A beta blocker will induce
bradycardia. The client should take her pulse rate for 1 min before self-
administration.
A nurse is caring for a client who has advanced heart failure. What action
should the nurse take? ---------CORRECT ANSWER-----------------Enforce
fluid restrictions - The nurse should enforce fluid restrictions to help reduce
fluid retention in the lungs and lower extremities.
A nurse is caring for a client who has late-stage heart failure and is
experiencing fluid volume overload. What finding should the nurse expect?
---------CORRECT ANSWER-----------------Weight gain of 1 kg (2.2 lb) in 1
day - A weight gain of 1 kg in 1 day alerts the nurse that the client might be
retaining fluid and is at risk of fluid volume overload. This is an indication
that the client's heart failure is worsening.
A nurse reinforcing discharge teaching with a client who has a new
permanent pacemaker. What information should the nurse include in the
teaching? ---------CORRECT ANSWER-----------------"Avoid lifting both arms
above your head when dressing." - The nurse should reinforce that the
client should avoid lifting her arm or shoulder on the side of the pacemaker
because dislodgement of the pacer leads can occur.
A nurse is collecting from a client who has right-sided heart failure. What
finding should the nurse expect? ---------CORRECT ANSWER-----------------
Dependent edema - Blood return from the venous system to the right
EXAM | ALL QUESTIONS AND CORRECT
DETAILED ANSWERS | GRADED A+ | VERIFIED
ANSWERS | LATEST VERSION
A nurse is checking for cardiac tamponade on a client who has pericarditis.
What action should the nurse take? ---------CORRECT ANSWER--------------
---Auscultate blood pressure for pulsus paradoxus - The client who has
cardiac tamponade will have pulsus paradoxus when the systolic blood
pressure is at least 10 mm Hg higher on expiration than on inspiration. This
occurs because of the sudden decrease in cardiac output from the fluid
compressing the atria and ventricles.
A nurse is caring for a client who had a myocardial infarction 5 days ago.
The client has a sudden onset of shortness of breath and begins coughing
frothy, pink sputum. The nurse auscultates loud, bubbly sounds on
inspiration. What adventitious breath sounds should the nurse document? -
--------CORRECT ANSWER-----------------Coarse crackles - A client who had
a recent myocardial infarction is at risk for left-sided heart failure. Crackles
are breath sounds caused by movement of air through airways partially or
intermittently occluded with fluid and are associated with heart failure and
frothy sputum. Crackling sounds are heard at the end of inspiration and are
not cleared by coughing.
A nurse is evaluating a client's repeat laboratory results 4 hr after
administering fresh frozen plasma (FFP). What laboratory values should
the nurse review? ---------CORRECT ANSWER-----------------Prothrombin
time - The nurse should review the client's prothrombin time after the
administration of FFP, which is plasma rich in clotting factors. FFP is
administered to treat acute clotting disorders. The desired effect is a
decrease in the prothrombin time.
,A nurse is assisting in the plan of care for a client who is having a
percutaneous transluminal coronary angioplasty (PTCA) with stent
placement. What action should the nurse anticipate in the postoperative
plan of care? ---------CORRECT ANSWER-----------------Initiate an aspirin
regimen - The nurse should plan to initiate an aspirin regimen or another
antiplatelet agent. The antiplatelet medication maintains the patency of the
stent by reducing platelet aggregation.
A nurse is collecting data from a client who has pericarditis. What
manifestations should the nurse expect? ---------CORRECT ANSWER-------
----------Dyspnea - The client who has pericarditis will experience dyspnea,
hiccups, and a nonproductive cough. These manifestations can indicate
heart failure from pericardial compression due to constrictive pericarditis or
cardiac tamponade.
A nurse is assisting in the preparation of a unit of packed red blood cells
(RBCs) for a client who has anemia. What action should the nurse take
first? ---------CORRECT ANSWER-----------------Witness the informed
consent - The nurse should apply the least invasive priority-setting
framework. This framework assigns priority to nursing interventions that are
least invasive to the client, as long as those interventions do not jeopardize
client safety. The nurse should take interventions that are not invasive to
the client before interventions that are invasive; therefore, as witnessing the
informed consent is the least invasive it is the action that should be
performed first. Unless it is an emergency, informed consent should be
obtained prior to initiating a blood transfusion on a client.
A nurse is collecting data from a client who has fluid volume overload
resulting from a cardiovascular disorder. What manifestations should the
nurse expect? ---------CORRECT ANSWER-----------------Jugular vein
distension - The increase in venous pressure due to excessive circulating
blood volume results in neck vein distension.
,Moist crackles - This is an indicator of pulmonary edema that can quickly
lead to death.
Increased heart rate - Fluid volume excess, or hypervolemia, is an
expansion of fluid volume in the extracellular fluid compartment. This
results in increased heart rate and bounding pulses.
A nurse is assisting in developing the plan of care for an older adult client
who is to receive a unit of placed red blood cells (RBCs). What action
should the nurse recommend? ---------CORRECT ANSWER-----------------
Verify the information on the packed RBCs with another nurse - The nurse
should verify the information on the label of the packed RBCs with another
nurse. She should also verify the information on the label with the
provider's order, the blood administration form from the blood bank, and
with the client armband and blood bracelet.
A nurse is caring for a client who has hemophilia. The client reports pain
and swelling in a joint following an injury. What action should the nurse
take? ---------CORRECT ANSWER-----------------Prepare for replacement of
the missing clotting factor - Hemophilia is a hereditary bleeding disorder in
which blood clots slowly and abnormal bleeding occurs. It is caused by a
deficiency in the most common clotting factor, factor VIII (hemophilia A).
Aggressive factor replacement is initiated to prevent hemarthrosis that can
result in long-term loss of range-of-motion in repeatedly affected joints.
A nurse is administering a loop diuretic to a client who has 3+ pitting
edema in the lower extremities. What actions should the nurse take? --------
-CORRECT ANSWER-----------------Monitor the client for ototoxicity - The
nurse should monitor the client for ototoxicity and reinforce that the client
should report any manifestations of hearing impairment while on the loop
diuretic. The nurse should use caution when a loop diuretic is used in
conjunction with other ototoxic medications, such as aminoglycoside
antibiotics.
, A nurse is reinforcing teaching about lifestyle changes with a client who
had a myocardial infection and has a new prescription for a beta blocker.
What statement by the client indicates an understanding of the teaching? --
-------CORRECT ANSWER-----------------"Before taking my medication, I will
check my blood pressure and radial pulse rate." - A beta blocker will induce
bradycardia. The client should take her pulse rate for 1 min before self-
administration.
A nurse is caring for a client who has advanced heart failure. What action
should the nurse take? ---------CORRECT ANSWER-----------------Enforce
fluid restrictions - The nurse should enforce fluid restrictions to help reduce
fluid retention in the lungs and lower extremities.
A nurse is caring for a client who has late-stage heart failure and is
experiencing fluid volume overload. What finding should the nurse expect?
---------CORRECT ANSWER-----------------Weight gain of 1 kg (2.2 lb) in 1
day - A weight gain of 1 kg in 1 day alerts the nurse that the client might be
retaining fluid and is at risk of fluid volume overload. This is an indication
that the client's heart failure is worsening.
A nurse reinforcing discharge teaching with a client who has a new
permanent pacemaker. What information should the nurse include in the
teaching? ---------CORRECT ANSWER-----------------"Avoid lifting both arms
above your head when dressing." - The nurse should reinforce that the
client should avoid lifting her arm or shoulder on the side of the pacemaker
because dislodgement of the pacer leads can occur.
A nurse is collecting from a client who has right-sided heart failure. What
finding should the nurse expect? ---------CORRECT ANSWER-----------------
Dependent edema - Blood return from the venous system to the right
