Med Surg: Cardiovascular ATI Practice A Questions
and Answers 100% Correct
A nurse is providing discharge teaching for a client who has a prescription for the transdermal
nitroglycerin patch. Which of the following instructions should the nurse include in the teachings?
A) Apply the new patch to the same site as the previous patch.
B) Place the patch on an area of skin away from skin folds and joints.
C)Keep the patch on 24 hr per day.
D) Replace the patch at the onset of angina.
Correct Answer is B.
Rationales:
Rotating the patch site can prevent skin
irritation.
The client should apply the patch to an area of
intact skin that has enough room for the patch to
fit smoothly.
The client should have a patch-free interval of 10
to 12 hr per day to prevent tolerance to the
medication.
The nurse should emphasize that nitroglycerin
patches offer ongoing prevention of angina
attacks. The patches do not treat angina attacks
because they do not take effect immediately.
A nurse in an emergency room is assessing a client who has bradydysrhythmia. Which of the following
findings should the nurse look out for?
A) Confusion
B) Friction rub
C) Hypertension
D) Dry skin
Correct Answer A
Rationales:
Bradydysrhythmia can cause decreased systemic perfusion, which can lead to confusion. Therefore,
the nurse should monitor the client's mental status.
The nurse should expect to hear a friction rub during cardiac auscultation on a client who has
pericarditis.
The nurse should monitor a client who has a bradydysrhythmia for hypotension.
The nurse should monitor a client who has a bradydysrhythmia for diaphoresis.
, A nurse is admitting a client who has a leg ulcer and a history of DM. The nurse should use which of
the following focused assessments to help differentiate between an arterial ulcer and a venous stasis
ulcer?
A) Explore the client's family history of peripheral vascular disease.
B) Note the presence or absence of pain at the ulcer site.
C) Inquire about the presence or absence of claudication.
D) Ask if the client has had a recent infection.
Correct Answer: C
Rationales:
Family history is important, but it does not help to differentiate between arterial and venous ulcers.
Both arterial and venous ulcers cause varying degrees of pain or discomfort.
Knowing if the client is experiencing claudication helps differentiate venous from arterial ulcers.
Clients who have arterial ulcers experience claudication, but those who have venous ulcers do not.
Both arterial and venous ulcers have the potential to become infected.
Claudication definition: a condition in which cramping pain in the leg is induced by exercise, typically
caused by obstruction of the arteries.
A nurse is providing teaching for a client who is 2 days postop following a heart transplant. Which of
the following statements should the nurse include in the teaching?
A) "You might no longer be able to feel chest pain."
B) "Your level of activity intolerance will not change."
C) "After 6 months, you will no longer need to restrict your sodium intake."
D) "You will be able to stop taking immunosuppressants after 12 months."
Correct Answer: A
Rationales:
Heart transplant clients usually are no longer able to feel chest pain due to the denervation of the
heart.
The client's activity tolerance should gradually improve as the healing process progresses.
The client will need to permanently maintain a diet that is restricted in sodium and fat.
The client will remain on immunosuppressants for the remainder of his life to help prevent rejection
of the heart.
A nurse is caring for a client who was admitted for treatment of left-sided heart failure with
intravenous loop diuretics and digitalis therapy. The client is experiencing weakness and irregular
heart rate. Which of the following actions should the nurse take first?
A) Obtain client's current weight.
and Answers 100% Correct
A nurse is providing discharge teaching for a client who has a prescription for the transdermal
nitroglycerin patch. Which of the following instructions should the nurse include in the teachings?
A) Apply the new patch to the same site as the previous patch.
B) Place the patch on an area of skin away from skin folds and joints.
C)Keep the patch on 24 hr per day.
D) Replace the patch at the onset of angina.
Correct Answer is B.
Rationales:
Rotating the patch site can prevent skin
irritation.
The client should apply the patch to an area of
intact skin that has enough room for the patch to
fit smoothly.
The client should have a patch-free interval of 10
to 12 hr per day to prevent tolerance to the
medication.
The nurse should emphasize that nitroglycerin
patches offer ongoing prevention of angina
attacks. The patches do not treat angina attacks
because they do not take effect immediately.
A nurse in an emergency room is assessing a client who has bradydysrhythmia. Which of the following
findings should the nurse look out for?
A) Confusion
B) Friction rub
C) Hypertension
D) Dry skin
Correct Answer A
Rationales:
Bradydysrhythmia can cause decreased systemic perfusion, which can lead to confusion. Therefore,
the nurse should monitor the client's mental status.
The nurse should expect to hear a friction rub during cardiac auscultation on a client who has
pericarditis.
The nurse should monitor a client who has a bradydysrhythmia for hypotension.
The nurse should monitor a client who has a bradydysrhythmia for diaphoresis.
, A nurse is admitting a client who has a leg ulcer and a history of DM. The nurse should use which of
the following focused assessments to help differentiate between an arterial ulcer and a venous stasis
ulcer?
A) Explore the client's family history of peripheral vascular disease.
B) Note the presence or absence of pain at the ulcer site.
C) Inquire about the presence or absence of claudication.
D) Ask if the client has had a recent infection.
Correct Answer: C
Rationales:
Family history is important, but it does not help to differentiate between arterial and venous ulcers.
Both arterial and venous ulcers cause varying degrees of pain or discomfort.
Knowing if the client is experiencing claudication helps differentiate venous from arterial ulcers.
Clients who have arterial ulcers experience claudication, but those who have venous ulcers do not.
Both arterial and venous ulcers have the potential to become infected.
Claudication definition: a condition in which cramping pain in the leg is induced by exercise, typically
caused by obstruction of the arteries.
A nurse is providing teaching for a client who is 2 days postop following a heart transplant. Which of
the following statements should the nurse include in the teaching?
A) "You might no longer be able to feel chest pain."
B) "Your level of activity intolerance will not change."
C) "After 6 months, you will no longer need to restrict your sodium intake."
D) "You will be able to stop taking immunosuppressants after 12 months."
Correct Answer: A
Rationales:
Heart transplant clients usually are no longer able to feel chest pain due to the denervation of the
heart.
The client's activity tolerance should gradually improve as the healing process progresses.
The client will need to permanently maintain a diet that is restricted in sodium and fat.
The client will remain on immunosuppressants for the remainder of his life to help prevent rejection
of the heart.
A nurse is caring for a client who was admitted for treatment of left-sided heart failure with
intravenous loop diuretics and digitalis therapy. The client is experiencing weakness and irregular
heart rate. Which of the following actions should the nurse take first?
A) Obtain client's current weight.
