ATI RN
Physical Exam Cardiovascular System
1. The client on digoxin has a potassium level of 3.0 mEq/L. What is the nurse’s priority action?
- A. Administer a potassium supplement
- B. Hold the digoxin and notify the healthcare provider
- C. Continue the current digoxin dose
- D. Administer Digibind
Correct answer: B
Rationale: The correct answer is to hold the digoxin and notify the healthcare provider. A potassium level of 3.0 mEq/L indicates hypokalemia, which can increase the risk of digoxin toxicity. Digoxin and low potassium levels can lead to serious cardiac arrhythmias. Administering a potassium supplement (choice A) without healthcare provider guidance can worsen the situation. Continuing the current digoxin dose (choice C) can further increase the risk of toxicity. Administering Digibind (choice D) is used in severe cases of digoxin toxicity, not for addressing low potassium levels.
2. Which condition is caused by a bacterium that primarily affects the lungs but can spread to other parts of the body?
- A. Tuberculosis
- B. Pneumonia
- C. Legionnaires' disease
- D. Histoplasmosis
Correct answer: A
Rationale: The correct answer is A, Tuberculosis. Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis, primarily affecting the lungs but can spread to other organs. Choice B, Pneumonia, is an infection that inflames the air sacs in one or both lungs. Choice C, Legionnaires' disease, is a severe form of pneumonia caused by the Legionella bacteria. Choice D, Histoplasmosis, is a fungal infection caused by inhaling spores of the Histoplasma capsulatum fungus.
3. The client on furosemide (Lasix) has a potassium level of 3.1 mEq/L. What is the nurse’s priority action?
- A. Administer a potassium supplement.
- B. Hold the furosemide and notify the healthcare provider.
- C. Continue the current dose of furosemide.
- D. Administer Digibind.
Correct answer: A
Rationale: The correct answer is to administer a potassium supplement. A potassium level of 3.1 mEq/L indicates hypokalemia, which can lead to serious complications like cardiac dysrhythmias. Therefore, the priority action is to address the low potassium level by administering a potassium supplement. Holding the furosemide (Choice B) may be necessary in the long term to prevent further potassium loss, but the immediate need is to correct the low potassium level. Continuing the current dose of furosemide (Choice C) without addressing the low potassium level can worsen hypokalemia. Administering Digibind (Choice D) is not indicated for low potassium levels; Digibind is used to treat digoxin toxicity.
4. Which of the following is a chronic lung disease that includes conditions such as chronic bronchitis and emphysema, characterized by obstructed airflow from the lungs?
- A. Chronic obstructive pulmonary disease (COPD)
- B. Pulmonary fibrosis
- C. Asthma
- D. Pneumonia
Correct answer: A
Rationale: The correct answer is A, Chronic obstructive pulmonary disease (COPD). COPD is a chronic lung disease that encompasses conditions like chronic bronchitis and emphysema. These conditions lead to obstructed airflow from the lungs, causing symptoms such as cough, shortness of breath, and wheezing. Choice B, Pulmonary fibrosis, involves scarring of the lung tissue, leading to breathing difficulties but is not specifically characterized by obstructed airflow like COPD. Asthma (Choice C) is a chronic condition characterized by airway inflammation and bronchoconstriction, not always resulting in obstructed airflow. Pneumonia (Choice D) is an acute infection of the lung tissue, causing symptoms like fever, cough, and difficulty breathing, but is not a chronic condition like COPD.
5. A client on a beta blocker has a blood pressure of 90/60 mm Hg. What is the nurse’s priority action?
- A. Hold the beta blocker and notify the healthcare provider.
- B. Administer the beta blocker as ordered.
- C. Administer a diuretic to reduce blood pressure.
- D. Continue to monitor the client and reassess in 30 minutes.
Correct answer: A
Rationale: The correct answer is to hold the beta blocker and notify the healthcare provider. A blood pressure of 90/60 mm Hg is already low, and beta blockers can further decrease blood pressure. Administering the beta blocker can potentially worsen the situation, leading to complications. Administering a diuretic or continuing to monitor the client without taking immediate action could delay necessary intervention. Therefore, holding the beta blocker and involving the healthcare provider promptly is crucial in this scenario.
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