ATI Medical-Surgical Assessment D
1. Question: A nurse is describing the process by which blood is ejected into circulation as the chambers of the heart become smaller. The instructor categorizes this action of the heart as what?
Answer: Systole.
2. Question: During a shift assessment, the nur...
1. Question: A nurse is describing the process by which blood is ejected into
circulation as the chambers of the heart become smaller. The instructor
categorizes this action of the heart as what?
Answer: Systole.
2. Question: During a shift assessment, the nurse is identifying the client's
point of maximum impulse (PMI). Where will the nurse best palpate the
PMI?
Answer: Left midclavicular line of the chest at the fifth intercostal space.
3. Question: The nurse is calculating a cardiac patient's pulse pressure. If the
patient's blood pressure is 122/76 mm Hg, what is the patient's pulse
pressure?
Answer: 46 mm Hg.
4. Question: The nurse is caring for a patient admitted with unstable angina.
The laboratory result for the initial troponin I is elevated. The nurse should
recognize what implication of this assessment finding?
Answer: This is an accurate indicator of myocardial injury.
5. Question: The nurse is conducting patient teaching about cholesterol levels.
When discussing the patient's elevated LDL and lowered HDL levels, the
patient shows an understanding of the significance of these levels by stating
what?
Answer: Increased LDL and decreased HDL increase my risk of coronary
artery disease.
, 6. Question: The physician has placed a central venous pressure (CVP)
monitoring line in an acutely ill patient to closely monitor right ventricular
function and venous blood return. The results show decreased CVP. What
does this indicate?
Answer: Possible hypovolemia.
7. Question: While auscultating a patient's heart sounds, the nurse hears an
extra heart sound immediately after the second heart sound (S2). An audible
S3 would be considered an expected finding in what patient?
Answer: A 20-year-old patient.
8. Question: The physical therapist notifies the nurse that a patient with
coronary artery disease (CAD) experiences a much greater-than-average
increase in heart rate during physical therapy. The nurse recognizes that an
increase in heart rate in a patient with CAD may result in what?
Answer: Myocardial ischemia.
9. Question: The nurse is caring for a patient with a history of heart disease.
What factor should the nurse identify as possibly contributing to a decrease
in cardiac output?
Answer: A heart rate of 54 bpm.
10.Question: The nurse is caring for an 82-year-old patient. The nurse knows
that changes in cardiac structure and function occur in older adults. What is
a normal change expected in the aging heart of an older adult?
Answer: Widening of the aorta.
11.Question: A resident of a long-term care facility has complained to the
nurse of chest pain. What aspect of the resident's pain would be most
suggestive of angina as the cause?
Answer: The pain occurs immediately following physical exertion.
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