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 client is receiving intravenous dopamine. What is the most important nursing assessment?

Correct answer: A

Rationale: The correct answer is to monitor heart rate and rhythm when a client is receiving intravenous dopamine. Dopamine is known to potentially cause arrhythmias, making this assessment crucial. While monitoring blood pressure, respiratory rate, and oxygen saturation are important nursing assessments, they are not the most critical when dopamine is being administered.

3. What condition is characterized by narrowed or blocked arteries in the legs or arms, leading to pain and mobility issues?

Correct answer: A

Rationale: The correct answer is A: Peripheral artery disease (PAD). PAD is a condition where the arteries in the legs or arms become narrowed or blocked, leading to pain and mobility issues. Choice B, Atherosclerosis, refers to the buildup of fats, cholesterol, and other substances in and on the artery walls, not specifically the narrowing or blockage in the extremities. Choice C, Raynaud's disease, is characterized by reduced blood flow to the extremities, leading to coldness, numbness, and color changes in the skin, but it is not primarily about narrowed or blocked arteries. Choice D, Varicose veins, involves enlarged, twisted veins usually in the legs, but it is not related to narrowed or blocked arteries causing pain and mobility issues.

4. 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.

5. 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.

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