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. When monitoring a client on dobutamine, what is the most important parameter to assess?

Correct answer: A

Rationale: The correct answer is A: Blood pressure. When a client is on dobutamine, it is crucial to closely monitor their blood pressure as dobutamine can cause significant changes in blood pressure. While heart rate is also important to monitor during this time, blood pressure is the most critical parameter to assess. Oxygen saturation and respiratory rate are also important parameters to monitor in a patient receiving dobutamine, but they are not as crucial as blood pressure in this scenario.

3. The nurse is administering an ACE inhibitor to a client. What is the most common side effect?

Correct answer: A

Rationale: The correct answer is A: Cough. Cough is a well-known side effect of ACE inhibitors due to an increase in bradykinin levels. This irritating cough can be bothersome to clients and should be monitored. Choice B, Dizziness, is not the most common side effect of ACE inhibitors. While ACE inhibitors can cause hypotension (Choice C), cough is more prevalent. Hyperkalemia (Choice D) is a possible side effect of ACE inhibitors but is less common compared to cough.

4. What is a chronic inflammatory disease that affects the small airways in the lungs, leading to episodes of wheezing, breathlessness, and coughing?

Correct answer: A

Rationale: Asthma is the correct answer. It is a chronic inflammatory disease that affects the small airways in the lungs, leading to symptoms like wheezing, breathlessness, and coughing. Asthma is commonly triggered by allergens, exercise, respiratory infections, and other factors. Choice B, COPD (Chronic Obstructive Pulmonary Disease), is characterized by airflow limitation and is often caused by smoking. Choice C, Bronchitis, is an inflammation of the bronchial tubes and can be acute or chronic. Choice D, Lung cancer, is a disease characterized by uncontrolled cell growth in lung tissues and is commonly associated with smoking or environmental factors.

5. Which structure serves as the major chemoreceptor of the heart?

Correct answer: A

Rationale: The correct answer is A, the carotid body. The carotid body is the major chemoreceptor of the heart responsible for detecting changes in blood oxygen, carbon dioxide, and pH levels. This specialized structure helps regulate the cardiovascular system's response to maintain appropriate oxygen levels in the blood. Choices B, C, and D are incorrect as they are not directly involved in chemoreception in the heart. The aortic body is primarily involved in blood pressure regulation, the vagus nerve is a cranial nerve responsible for parasympathetic innervation, and the SA node is known as the heart's natural pacemaker.

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