the nurse is caring for a heart client on digoxin and notes a potassium level of 25 what is the appropriate priority nursing intervention
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Nursing Elites

ATI RN

Cardiovascular System Exam

1. The nurse is caring for a heart client on digoxin and notes a potassium level of 2.5. What is the appropriate priority nursing intervention?

Correct answer: C

Rationale: The correct answer is C. When caring for a client on digoxin with a low potassium level, the priority nursing intervention is to check the digoxin level. Low potassium can increase the risk of digoxin toxicity. Checking the digoxin level will help determine if any adjustments to the medication regimen are needed to prevent potential harm. Choice A is incorrect as a potassium level of 2.5 is low, not normal. Choice B is not the priority as simply giving potassium may not address the underlying issue of potential digoxin toxicity. Choice D is not the initial action to take without assessing the digoxin level first.

2. What is a condition where the airways become inflamed and narrow, making breathing difficult?

Correct answer: A

Rationale: Asthma is the correct answer. It is a condition characterized by inflammation, narrowing, and swelling of the airways, leading to symptoms like wheezing, shortness of breath, and coughing. Bronchitis is the inflammation of the bronchial tubes; Pleurisy is inflammation of the tissues that line the lungs and chest cavity; Tuberculosis is a bacterial infection that mainly affects the lungs.

3. During which process does coronary artery blood flow to the myocardium occur during diastole, when coronary vascular resistance is reduced?

Correct answer: A

Rationale: The correct answer is A: Coronary perfusion pressure. Coronary perfusion pressure refers to the process of coronary artery blood flow to the myocardium during diastole when coronary vascular resistance is reduced. This process ensures that the myocardium receives sufficient oxygen and nutrients for proper functioning. Choice B, Coronary vascular resistance, is the opposite of what is described in the question. During coronary perfusion, resistance is reduced to enhance blood flow. Choices C and D, Diastolic filling and Ventricular ejection, do not directly relate to the process of coronary artery blood flow during diastole.

4. Which condition involves the tearing of the aorta, leading to severe pain and internal bleeding?

Correct answer: A

Rationale: The correct answer is Aortic dissection. Aortic dissection is a life-threatening condition where the inner layer of the aorta tears, causing severe chest or back pain and internal bleeding, requiring immediate medical attention. Choice B, aneurysm, involves a bulging or weakening of a blood vessel wall, which is different from a tear in the aorta. Choices C and D, stroke and myocardial infarction, do not directly involve the tearing of the aorta and are distinct conditions.

5. Which valve prevents backflow of blood into the left ventricle from the aorta?

Correct answer: A

Rationale: The correct answer is Aortic valve. The aortic valve is positioned between the left ventricle and the aorta. It prevents blood from flowing back into the left ventricle after it has been pumped into the aorta. The mitral valve (Choice B) is located between the left atrium and the left ventricle, the tricuspid valve (Choice C) is between the right atrium and right ventricle, and the pulmonary valve (Choice D) is situated between the right ventricle and the pulmonary artery. Therefore, they are not responsible for preventing backflow from the aorta into the left ventricle.

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