the client is receiving digoxin and complains of nausea what is the nurses priority action
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Nursing Elites

ATI RN

Cardiovascular System Practice Exam

1. The client is receiving digoxin and complains of nausea. What is the nurse’s priority action?

Correct answer: A

Rationale: The correct answer is to check the client’s digoxin level (Choice A). Nausea can be a sign of digoxin toxicity, so assessing the digoxin level is crucial to determine if the medication dosage needs adjustment. Continuing the current dose of digoxin (Choice B) may worsen the symptoms if toxicity is present. Administering an antiemetic (Choice C) may provide temporary relief but does not address the underlying issue of digoxin toxicity. Discontinuing digoxin immediately (Choice D) without assessing the digoxin level can be harmful if the medication is within the therapeutic range.

2. Which condition is characterized by fluid collection in the lungs, making it difficult to breathe?

Correct answer: A

Rationale: The correct answer is A, Pulmonary edema. Pulmonary edema is a condition where fluid accumulates in the air sacs of the lungs, causing breathing difficulty. Pleurisy (choice B) is inflammation of the pleura causing chest pain. Pleural effusion (choice C) is the buildup of excess fluid in the pleural space, the area between the layers of tissue that line the lungs and chest cavity. Pneumothorax (choice D) is the presence of air in the pleural space, which can cause a lung to collapse.

3. A client on an ACE inhibitor reports a persistent cough. What is the nurse’s best response?

Correct answer: B

Rationale: The correct answer is B. A persistent cough in a client on an ACE inhibitor may indicate a serious side effect that requires discontinuation of the medication. Instructing the client to report the cough to the healthcare provider is essential for proper evaluation and management. Choice A is incorrect because simply reassuring the client may delay necessary action. Choice C is incorrect as using a humidifier may not address the underlying cause of the cough. Choice D is incorrect because taking a cough suppressant without healthcare provider guidance may mask symptoms without addressing the cause.

4. What is a condition where the heart beats too fast, reducing its ability to pump blood effectively?

Correct answer: A

Rationale: Tachycardia is the correct answer because it is a condition characterized by a fast heart rate, which can decrease the heart's efficiency in pumping blood. Bradycardia, on the other hand, refers to a slow heart rate, which is the opposite of what is described in the question. Arrhythmia is a general term for any irregularity in the heart's rhythm, not necessarily specifically related to a fast heart rate. Ventricular fibrillation is a life-threatening arrhythmia where the heart's lower chambers quiver instead of pumping blood effectively, but it is not specifically characterized by a fast heart rate.

5. What is a condition where the lung's air sacs become inflamed and fill with fluid or pus, causing cough, fever, chills, and difficulty breathing?

Correct answer: A

Rationale: Pneumonia is the correct answer. It is an infection that inflames the air sacs in one or both lungs, leading to the accumulation of fluid or pus, which results in symptoms such as cough, fever, chills, and difficulty breathing. Tuberculosis (choice B) is a bacterial infection affecting the lungs but does not typically cause the same acute symptoms as described. Asthma (choice C) is a chronic respiratory condition characterized by inflammation and narrowing of the airways, not specifically involving the air sacs. Bronchitis (choice D) is an inflammation of the bronchial tubes, not the air sacs in the lungs, and does not typically cause the same symptoms as pneumonia.

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