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. Which test measures how well the lungs work by assessing the amount of air the lungs can hold and how quickly air can be exhaled?

Correct answer: A

Rationale: The correct answer is A, Spirometry. Spirometry is a pulmonary function test that evaluates lung function by measuring the amount of air a person can exhale and how quickly, assisting in the diagnosis of conditions such as asthma and COPD. Choices B, C, and D are incorrect because Pulse oximetry measures oxygen saturation in the blood, Arterial blood gas (ABG) evaluates blood pH, oxygen, and carbon dioxide levels, and a Chest X-ray provides an image of the lungs but does not measure lung function.

3. What is the average cardiac output?

Correct answer: B

Rationale: The correct answer is B: Approximately 4 to 8 L per minute. Cardiac output is defined as the volume of blood the heart pumps per minute, typically ranging between 4 to 8 liters. Choices A, C, and D provide ranges that are either too narrow or outside the standard average values for cardiac output, making them incorrect.

4. What structures hold up the AV valves and are anchored to the ventricular wall by the papillary muscles?

Correct answer: A

Rationale: The correct answer is A: Chordae tendineae. Chordae tendineae are fibrous cords that connect the AV valves to the papillary muscles, preventing the valves from inverting during ventricular contraction. Papillary muscles (choice B) anchor the chordae tendineae to the ventricular wall but do not hold up the AV valves directly. Semilunar valves (choice C) are located between the ventricles and the major arteries and are not involved in holding up the AV valves. The aortic valve (choice D) is one of the semilunar valves and is not responsible for holding up the AV valves.

5. What is a condition where the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients?

Correct answer: A

Rationale: A stroke occurs when the blood supply to part of the brain is interrupted or reduced, leading to brain cell death and potential disability. Choice B, a heart attack, involves a blockage in the blood vessels that supply the heart muscle. Choice C, a pulmonary embolism, is a blockage in one of the pulmonary arteries in the lungs. Choice D, pneumonia, is an infection that inflames the air sacs in one or both lungs.

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