ATI PHYSIOLOGICAL NEEDS
Cardiovascular Review
Exam
Q&A
2024
,1. A patient with a history of hypertension and angina is admitted to the
hospital with chest pain. The nurse administers nitroglycerin sublingually
and monitors the patient's vital signs. Which of the following findings
indicates that the nitroglycerin is effective? (Select all that apply.)
A) The patient's blood pressure decreases to 120/80 mmHg.
B) The patient's heart rate increases to 100 beats per minute.
C) The patient's chest pain subsides within 5 minutes.
D) The patient's skin becomes warm and flushed.
E) The patient's respiratory rate decreases to 12 breaths per minute.
Answer: A, C, D
Rationale: Nitroglycerin is a vasodilator that reduces the preload and
afterload on the heart, lowering the blood pressure and decreasing the
oxygen demand of the myocardium. It also dilates the coronary arteries,
increasing the blood flow to the ischemic areas of the heart. These effects
can relieve angina and lower the risk of myocardial infarction.
Nitroglycerin can cause reflex tachycardia, which is an undesirable side
effect that increases the cardiac workload. It can also cause headache,
dizziness, and hypotension. Nitroglycerin does not affect the respiratory
rate.
2. A nurse is caring for a patient who has just undergone coronary artery
bypass graft (CABG) surgery. The nurse notices that the patient's chest
tube drainage has increased from 50 mL/hour to 150 mL/hour in the last
hour. What is the nurse's priority action?
A) Notify the surgeon immediately.
B) Clamp the chest tube and observe for changes.
C) Administer a bolus of normal saline intravenously.
D) Document the finding and continue to monitor.
Answer: A
Rationale: An increase in chest tube drainage after CABG surgery can
indicate bleeding or cardiac tamponade, which are life-threatening
complications that require immediate intervention. The nurse should
notify the surgeon as soon as possible and prepare for emergency
measures such as chest tube reinsertion, pericardiocentesis, or surgery.
Clamping the chest tube can worsen the situation by increasing the
intrathoracic pressure and impairing cardiac output. Administering a bolus
of normal saline can increase the fluid volume and exacerbate the bleeding
, or tamponade. Documenting and monitoring are not sufficient actions in
this situation.
3. A nurse is teaching a patient who has been prescribed warfarin
(Coumadin) for atrial fibrillation. Which of the following statements by
the patient indicates a need for further teaching?
A) "I will avoid eating foods that are high in vitamin K, such as spinach
and kale."
B) "I will use an electric razor instead of a blade when I shave."
C) "I will check my pulse daily and report any irregularities to my doctor."
D) "I will take aspirin for any headaches or pain that I have."
Answer: D
Rationale: Warfarin is an anticoagulant that inhibits the synthesis of
vitamin K-dependent clotting factors in the liver. It is used to prevent
thromboembolic events in patients with atrial fibrillation, which is a risk
factor for stroke. Patients taking warfarin should avoid foods that are high
in vitamin K, such as leafy green vegetables, because they can antagonize
the effect of warfarin and increase the risk of clotting. They should also
use caution when performing activities that can cause bleeding, such as
shaving, brushing teeth, or using sharp objects. They should use an
electric razor instead of a blade, soft-bristled toothbrush instead of a hard
one, and avoid flossing or picking at their gums. They should also avoid
taking other medications that can increase the bleeding risk, such as
aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), or herbal
supplements. They should check their pulse daily and report any
irregularities, such as skipped beats, palpitations, or rapid rate, to their
doctor, because these can indicate worsening of atrial fibrillation or
inadequate anticoagulation. They should also have regular blood tests to
monitor their international normalized ratio (INR), which is a measure of
how long it takes their blood to clot.
4. A nurse is assessing a patient who has heart failure and is receiving
furosemide (Lasix) and digoxin (Lanoxin). The nurse notes that the
patient's serum potassium level is 3.2 mEq/L and serum digoxin level is
2.1 ng/mL. What are the signs and symptoms of digoxin toxicity that the
nurse should monitor for? (Select all that apply.)
A) Nausea and vomiting
B) Yellow-green halos around lights
Cardiovascular Review
Exam
Q&A
2024
,1. A patient with a history of hypertension and angina is admitted to the
hospital with chest pain. The nurse administers nitroglycerin sublingually
and monitors the patient's vital signs. Which of the following findings
indicates that the nitroglycerin is effective? (Select all that apply.)
A) The patient's blood pressure decreases to 120/80 mmHg.
B) The patient's heart rate increases to 100 beats per minute.
C) The patient's chest pain subsides within 5 minutes.
D) The patient's skin becomes warm and flushed.
E) The patient's respiratory rate decreases to 12 breaths per minute.
Answer: A, C, D
Rationale: Nitroglycerin is a vasodilator that reduces the preload and
afterload on the heart, lowering the blood pressure and decreasing the
oxygen demand of the myocardium. It also dilates the coronary arteries,
increasing the blood flow to the ischemic areas of the heart. These effects
can relieve angina and lower the risk of myocardial infarction.
Nitroglycerin can cause reflex tachycardia, which is an undesirable side
effect that increases the cardiac workload. It can also cause headache,
dizziness, and hypotension. Nitroglycerin does not affect the respiratory
rate.
2. A nurse is caring for a patient who has just undergone coronary artery
bypass graft (CABG) surgery. The nurse notices that the patient's chest
tube drainage has increased from 50 mL/hour to 150 mL/hour in the last
hour. What is the nurse's priority action?
A) Notify the surgeon immediately.
B) Clamp the chest tube and observe for changes.
C) Administer a bolus of normal saline intravenously.
D) Document the finding and continue to monitor.
Answer: A
Rationale: An increase in chest tube drainage after CABG surgery can
indicate bleeding or cardiac tamponade, which are life-threatening
complications that require immediate intervention. The nurse should
notify the surgeon as soon as possible and prepare for emergency
measures such as chest tube reinsertion, pericardiocentesis, or surgery.
Clamping the chest tube can worsen the situation by increasing the
intrathoracic pressure and impairing cardiac output. Administering a bolus
of normal saline can increase the fluid volume and exacerbate the bleeding
, or tamponade. Documenting and monitoring are not sufficient actions in
this situation.
3. A nurse is teaching a patient who has been prescribed warfarin
(Coumadin) for atrial fibrillation. Which of the following statements by
the patient indicates a need for further teaching?
A) "I will avoid eating foods that are high in vitamin K, such as spinach
and kale."
B) "I will use an electric razor instead of a blade when I shave."
C) "I will check my pulse daily and report any irregularities to my doctor."
D) "I will take aspirin for any headaches or pain that I have."
Answer: D
Rationale: Warfarin is an anticoagulant that inhibits the synthesis of
vitamin K-dependent clotting factors in the liver. It is used to prevent
thromboembolic events in patients with atrial fibrillation, which is a risk
factor for stroke. Patients taking warfarin should avoid foods that are high
in vitamin K, such as leafy green vegetables, because they can antagonize
the effect of warfarin and increase the risk of clotting. They should also
use caution when performing activities that can cause bleeding, such as
shaving, brushing teeth, or using sharp objects. They should use an
electric razor instead of a blade, soft-bristled toothbrush instead of a hard
one, and avoid flossing or picking at their gums. They should also avoid
taking other medications that can increase the bleeding risk, such as
aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), or herbal
supplements. They should check their pulse daily and report any
irregularities, such as skipped beats, palpitations, or rapid rate, to their
doctor, because these can indicate worsening of atrial fibrillation or
inadequate anticoagulation. They should also have regular blood tests to
monitor their international normalized ratio (INR), which is a measure of
how long it takes their blood to clot.
4. A nurse is assessing a patient who has heart failure and is receiving
furosemide (Lasix) and digoxin (Lanoxin). The nurse notes that the
patient's serum potassium level is 3.2 mEq/L and serum digoxin level is
2.1 ng/mL. What are the signs and symptoms of digoxin toxicity that the
nurse should monitor for? (Select all that apply.)
A) Nausea and vomiting
B) Yellow-green halos around lights
