the client is on nitroglycerin and reports chest pain what is the nurses priority action
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Nursing Elites

ATI RN

Cardiovascular System Exam Questions

1. The client is on nitroglycerin and reports chest pain. What is the nurse’s priority action?

Correct answer: D

Rationale: The correct answer is D: Notify the healthcare provider immediately. If a client on nitroglycerin reports chest pain, the priority action is to notify the healthcare provider immediately. This is crucial to ensure prompt reassessment of the client's condition and treatment plan. Administering nitroglycerin, morphine, or aspirin without consulting the healthcare provider first can be risky as the chest pain may indicate a need for a change in treatment or further evaluation. Administering medications without proper assessment and guidance can lead to complications and is not recommended in this scenario.

2. What is a condition where the lung's air sacs (alveoli) are damaged and enlarged, leading to breathlessness?

Correct answer: A

Rationale: Emphysema is the correct answer. It is a condition where the air sacs in the lungs are damaged and enlarged, leading to breathlessness. Chronic bronchitis is characterized by inflammation of the bronchial tubes, not the alveoli. Asthma involves airway inflammation and constriction, not alveolar damage. Pulmonary fibrosis is a condition where lung tissue becomes thickened and scarred, different from the alveolar damage seen in emphysema.

3. The client on enoxaparin (Lovenox) is scheduled for surgery. What is the nurse’s priority action?

Correct answer: A

Rationale: The correct answer is A: Hold the enoxaparin and notify the healthcare provider. Enoxaparin, being an anticoagulant, should be held before surgery to reduce the risk of excessive bleeding during the procedure. It is crucial to inform the healthcare provider to determine the appropriate management plan. Choice B is incorrect because administering enoxaparin before surgery can increase the risk of bleeding. Choice C is incorrect as vitamin K administration is not typically indicated in this situation. Choice D is incorrect because monitoring the client's INR and proceeding with surgery without addressing the enoxaparin can lead to significant bleeding complications.

4. The client on furosemide (Lasix) is at risk for which electrolyte imbalance?

Correct answer: B

Rationale: The correct answer is B: Hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss, resulting in hypokalemia. This electrolyte imbalance is a significant risk associated with diuretic use. Choices A, C, and D are incorrect. Hyperkalemia (choice A) is not typically associated with furosemide use. Hyponatremia (choice C) and hypernatremia (choice D) are related to sodium levels, not potassium levels affected by furosemide.

5. The nurse is administering digoxin to a client with a heart rate of 45 bpm. 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 heart rate of 45 bpm is already low, and digoxin can further decrease the heart rate, leading to serious complications like bradycardia or heart block. Administering the medication can exacerbate the bradycardia, hence it should be withheld. Increasing the dose of digoxin is contraindicated due to the client's low heart rate. Monitoring the heart rate alone without taking immediate action to withhold the medication is not the priority when faced with the risk of further lowering the heart rate.

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