the client is receiving digoxin and has a potassium level of 28 meql what is the nurses priority action
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Nursing Elites

ATI RN

Cardiovascular System Exam

1. The client is receiving digoxin and has a potassium level of 2.8 mEq/L. What is the nurse’s priority action?

Correct answer: A

Rationale: The correct answer is to hold the digoxin and notify the healthcare provider. A potassium level of 2.8 mEq/L indicates hypokalemia, which can increase the risk of digoxin toxicity. Holding the medication and informing the healthcare provider is crucial to prevent adverse effects. Choice B is incorrect because increasing the dose of digoxin would further raise the risk of toxicity. Choice C is incorrect as continuing the current dose could exacerbate the toxicity risk. Choice D is incorrect because administering potassium supplements alone is not sufficient to address the potential digoxin toxicity; the first step should be to hold the digoxin and seek further guidance.

2. The nurse is teaching a client about the side effects of beta blockers. What is the most important side effect to monitor?

Correct answer: A

Rationale: The most important side effect to monitor when a client is on beta blockers is hypotension. Beta blockers can cause a significant drop in blood pressure, especially at the initiation of therapy. Monitoring for hypotension is crucial to prevent complications such as dizziness, syncope, or falls. While bradycardia can also occur with beta blockers, hypotension takes precedence due to its immediate impact on perfusion. Hyperkalemia is not a common side effect of beta blockers. Tachycardia is actually a condition that beta blockers aim to treat, so it is not a side effect to monitor.

3. What is the condition where the lung collapses due to air leaking into the space between the lung and chest wall?

Correct answer: A

Rationale: Pneumothorax is the correct answer. It is the collapse of a lung due to air leaking into the space between the lung and chest wall. This condition often requires emergency treatment. Choice B, Pleural effusion, is the buildup of excess fluid between the layers of the pleura outside the lung, not air. Choice C, Pulmonary fibrosis, is a lung disease characterized by scarring and thickening of lung tissue, not related to lung collapse. Choice D, Lung cancer, is the uncontrolled growth of abnormal cells in the lung, not directly causing lung collapse.

4. Which condition is characterized by chest pain due to reduced blood flow to the heart muscle?

Correct answer: A

Rationale: The correct answer is A, Angina. Angina is chest pain or discomfort caused by reduced blood flow to the heart muscle, often due to coronary artery disease. Choice B, Myocardial infarction, involves the death of heart muscle tissue due to a lack of blood supply, presenting with symptoms similar to angina but more severe. Pericarditis (Choice C) is inflammation of the pericardium, the sac surrounding the heart, which may cause chest pain but is not primarily due to reduced blood flow. Arrhythmia (Choice D) refers to abnormal heart rhythms but is not directly related to chest pain due to reduced blood flow.

5. Which test measures how well the lungs work by assessing the amount of air the lungs can hold and how quickly air can be exhaled?

Correct answer: A

Rationale: The correct answer is A, Spirometry. Spirometry is a pulmonary function test that evaluates lung function by measuring the amount of air a person can exhale and how quickly, assisting in the diagnosis of conditions such as asthma and COPD. Choices B, C, and D are incorrect because Pulse oximetry measures oxygen saturation in the blood, Arterial blood gas (ABG) evaluates blood pH, oxygen, and carbon dioxide levels, and a Chest X-ray provides an image of the lungs but does not measure lung function.

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