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. The nurse is preparing to administer a beta blocker to a client with hypertension. What is the priority assessment?

Correct answer: B

Rationale: The correct answer is to check the client's blood pressure. Before administering a beta blocker to a client with hypertension, assessing the blood pressure is crucial because beta blockers can cause hypotension, potentially leading to adverse effects. Checking the heart rate may also be important but is secondary to monitoring the blood pressure in this scenario. Respiratory rate and temperature assessments are not directly related to assessing the client's response to a beta blocker in hypertension management, making choices C and D less relevant.

3. What is a severe and often sudden allergic reaction that can lead to breathing difficulties and anaphylactic shock?

Correct answer: A

Rationale: Anaphylaxis is the correct answer. It is a severe allergic reaction that can result in difficulty breathing, a drop in blood pressure, and even anaphylactic shock if not treated promptly. Choice B, allergic rhinitis, is characterized by symptoms such as a runny or stuffy nose, sneezing, and itching. Choice C, bronchospasm, refers to the sudden constriction of the muscles in the walls of the bronchioles, leading to breathing difficulties. Choice D, asthma attack, involves the inflammation and narrowing of the airways, resulting in symptoms like wheezing, coughing, and chest tightness.

4. Which chronic respiratory condition is characterized by the narrowing and inflammation of the airways, leading to difficulty breathing?

Correct answer: A

Rationale: Asthma is the correct answer. It is a chronic respiratory condition where the airways become inflamed and narrowed, leading to episodes of wheezing, breathlessness, chest tightness, and coughing. Asthma is characterized by reversible airflow obstruction, differentiating it from COPD, which involves irreversible airflow limitation. Bronchitis is an inflammation of the bronchial tubes without the same reversible airflow obstruction seen in asthma. Pneumonia is an infection of the lung tissue and does not involve chronic inflammation and narrowing of the airways like asthma.

5. The healthcare provider is monitoring a client on an ACE inhibitor. What lab value is most important to monitor?

Correct answer: A

Rationale: The correct answer is A: Potassium. When a client is on an ACE inhibitor, it is crucial to monitor potassium levels because ACE inhibitors can lead to an increase in potassium, potentially causing hyperkalemia. Monitoring sodium levels (Choice B) is not as critical in this scenario. Creatinine levels (Choice C) are important for assessing kidney function but are not the most crucial lab value to monitor with ACE inhibitors. Calcium levels (Choice D) are not directly affected by ACE inhibitors and are not the priority for monitoring in this case.

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