the client is on digoxin and has severe digoxin toxicity what is the nursing priority action
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Nursing Elites

ATI RN

Physical Exam Cardiovascular System

1. The client is on digoxin and has severe digoxin toxicity. What is the nursing priority action?

Correct answer: B

Rationale: The correct answer is to give Digibind as an antidote in cases of severe digoxin toxicity. Digibind works by binding to digoxin and preventing it from causing further harm. Checking the potassium level (choice A) is important but not the priority when the client has severe toxicity. Changing the dosing to every other day (choice C) is not appropriate in the setting of severe toxicity where immediate action is required. Giving a potassium supplement (choice D) may be needed eventually, but the priority is to administer Digibind to counteract the toxic effects of digoxin.

2. What test measures the electrical activity of the heart to detect arrhythmias and other heart conditions?

Correct answer: A

Rationale: An electrocardiogram (ECG or EKG) is used to measure the heart's electrical activity, aiding in the detection of arrhythmias and other heart conditions. Choice B, a chest X-ray, is not used to measure electrical activity but to visualize the structures of the chest. Choice C, a stress test, evaluates the heart's response to exertion and is not primarily focused on measuring electrical activity. Choice D, an arterial blood gas (ABG) test, is used to assess oxygen and carbon dioxide levels in the blood, not the heart's electrical activity.

3. Which test uses sound waves to create images of the heart, allowing doctors to assess its structure and function?

Correct answer: A

Rationale: The correct answer is A: Echocardiogram. An echocardiogram is a test that uses sound waves to create images of the heart, enabling doctors to assess its structure and function. This imaging technique is particularly useful in detecting abnormalities such as valve disease. Choices B, C, and D are incorrect because MRI, CT scans, and X-rays use different imaging technologies that do not rely on sound waves to visualize the heart.

4. The client is on nitroglycerin patches. What should the nurse include in the client’s education?

Correct answer: A

Rationale: The correct answer is A: 'Rotate the application site with each new patch.' When educating a client using nitroglycerin patches, it is essential to rotate the application site to prevent skin irritation. Choice B is incorrect because applying the patch at the same time each day is not a critical aspect of patch application. Choice C is incorrect as nitroglycerin patches are usually left on for a specific period, typically 12 to 14 hours, before being replaced. Choice D is incorrect because applying the patch to the same site each time can lead to skin irritation and tolerance development.

5. In cases of myocardial infarction leading to shock, which medication is appropriate to counteract shock?

Correct answer: B

Rationale: In cases of myocardial infarction leading to shock, dopamine is the drug of choice. Dopamine helps increase blood pressure and improve blood flow to vital organs, making it beneficial in managing shock. Atropine is mainly used for symptomatic bradycardia, not for shock. Digoxin is a cardiac glycoside used in heart failure and atrial fibrillation, not for managing shock. Adenosine is typically used for diagnosing and treating supraventricular tachycardias, not for shock associated with myocardial infarction.

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