ATI Rationales - Cardiac

Question 1

What type of pain can be expected with an abdominal aortic aneurysm that is extending.

Answer 1

Abdominal aortic aneurysm involves a widening, stretching, or ballooning of the aorta. Back and abdominal pain indicate that the aneurysm is extending downward and pressing on lumbar spinal nerve roots causing pain.

Question 2

What will happen to BP if abdominal aortic aneurysm is extending?

Answer 2

Decrease

Question 3

What should the nurse look for in a client who had an MI 24 hours ago?

Answer 3

Ventricular Dysrhythmias

Question 4

After an MI what can cause arrhythmias?

Answer 4

Irritable electric system

Ischemic tissue

Question 5

What is pericarditis usually the result of?

Answer 5

Trauma

Question 6

Blunt chest trauma can lead to damage in which of the four chambers of the heart and why?

Answer 6

The right ventricle lies directly behind the sternum. In a blunt injury, the impact of the right ventricle against the sternum will cause the greatest area of damage.

Question 7

What is the purpose of a percutaneous transluminal coronary angioplasty (PTCA)

Answer 7

Dilation.
A PTCA dilates an obstructed coronary artery. A catheter with an inflatable balloon tip is inserted into the obstructed coronary artery. The balloon is inflated, compressing atherosclerotic plaque against the coronary artery wall, resulting in dilation of the artery.

Question 8

Clients who have frequent blood transfusions are at a risk for:

Answer 8

Iron Toxicity

Question 9

Which value should the nurse analyze to evaluate a client’s response to a transfusion of fresh frozen platelets?

Answer 9

PTT
FFP is plasma rich in clotting factors. It is given to treat acute clotting disorders, and the desired effect is a decrease in the prothrombin time.

Question 10

A nurse is caring for a client admitted with a suspected dissecting aortic aneurysm. The nurse should monitor the client for what ?

Answer 10

Back pain
is a cardinal sign that will cause the nurse to suspect a dissecting aortic aneurysm. Other key manifestations of a dissecting aortic aneurysm include hypotension and tachycardia.

Question 11

Treatment for pernicious anemia

Answer 11

Monthly B-12 shots

Question 12

Itching and hives during a blood transfusion what do you do?

Answer 12

Stop infusion
These are manifestations of an allergic reaction to the transfusion, and this is the proper first response to symptoms of any type of blood reaction. If a client shows manifestations of an allergic response (to blood or a medication), the exposure must be stopped immediately.

Question 13

Impaired venous circulation in the legs would look like:

Answer 13

Areas of reddish, brown pigmentation

Question 14

Pitting edema in lower legs is evidence of

Answer 14

This is a symptom of congestive heart failure due to coronary artery disease.

Question 15

Client with arteriosclerosis obliterans would have legs that looked like:

Answer 15

-Thin, shiny skin with minimal body hair
Arteriosclerosis obliterans is a disease of the blood vessels characterized by narrowing of the arteries in the legs and feet. This causes a decrease in blood flow to the distal extremities which can lead to tissue damage. Common symptoms are intermittent claudication (leg pain with exercise), cold or numb feet at rest, loss of hair on the lower legs, and weakened pulses.

Question 16

Client with pericarditis would have what kind of breathing and resp rate?

Answer 16

When pericarditis is present, the client will experience dyspnea and tachypnea. Chest pain with pericarditis will increase with deep inspiration due to increased pressure on the inflamed pericardial sac. This will make the client reluctant to take deep breaths resulting in dyspnea and tachypnea.

Question 17

How would a low-potassium level appear on the EKG

Answer 17

A flattened T wave or the development of U waves

Question 18

arrhythmias occurring with toxic digitalis levels.

Answer 18

Bradycardia, ventricular bigeminy, or ventricular tachycardia

Question 19

The EKG pattern anticipated with a low hemoglobin

Answer 19

tachycardia.

Question 20

Transient abnormal PMI (point of maximal impulse) could occur during:

Answer 20

acute angina attack

Question 21

Pulsus paradoxus is an abnormal decrease in systolic blood pressure during inspiration and is seen in (3)

Answer 21

cardiac tamponade, pericarditis, and advanced heart failure.

Question 22

A client who had a recent myocardial infarction is at risk for what condition?

Answer 22

for congestive heart failure (CHF).

Question 23

What must be verified before giving blood?

Answer 23

Expiration date and time:
the nurse is responsible for ensuring the client receives the correct unit of blood by checking the identity of the blood product, the client, and the compatibility (blood type and Rh factor) of the blood and the client.

Question 24

An atrial rate of 300, with 80 QRS complex per min is what?

Answer 24

Atrial - flutter

Question 25

What is needed to verify placement in hemodynamic monitoring?

Answer 25

chest xray

Question 26

Bed position during hemodynamic readings?

Answer 26

45 degrees

Question 27

At what level should the transducer be placed for hemodynamic monitoring?

Answer 27

phlebostatic axis (right atrium)

Question 28

Hypovolemic shock is associated with:

Answer 28

fluid loss

Question 29

Heart failure is associated with:

Answer 29

left ventricular failure

Question 30

cor pulmonale is associated with the ____ side of the heart

Answer 30

right

Question 31

Following angiography what is it important for the client to do?

Answer 31

Lie still due to increased bleeding risk

Question 32

Can the proximal CVP lumen of a PA catheter be used for IV fluid administration?

Answer 32

Yes