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 fibers distribute the electrical impulse to the ventricles, causing them to contract?

Correct answer: A

Rationale: The correct answer is Purkinje fibers. Purkinje fibers are specialized conducting fibers that distribute the electrical impulse to the ventricles, leading to their contraction. The SA node (sinoatrial node) is responsible for initiating the electrical impulse in the heart, the AV node (atrioventricular node) delays the impulse to allow for proper atrial contraction before ventricular contraction, and the Bundle of His transmits the impulse from the AV node to the ventricles. Therefore, choices B, C, and D are not the correct options for fibers directly distributing the impulse to the ventricles.

3. What is the term for a condition where the lung collapses due to air leaking into the space between the lung and the chest wall?

Correct answer: A

Rationale: Pneumothorax is the correct answer for this question. Pneumothorax is the collapse of a lung caused by the presence of air in the pleural space between the lung and chest wall. This condition can lead to chest pain, shortness of breath, and may require emergency treatment such as chest tube insertion to remove the air. Pleural effusion is the accumulation of fluid in the pleural space, not air. Atelectasis is the collapse or closure of a lung resulting in reduced or absent gas exchange. Pulmonary fibrosis is a condition characterized by scarring and thickening of lung tissue, not related to air leaking into the pleural space.

4. When administering furosemide (Lasix) to a client, which lab value is most important to monitor?

Correct answer: A

Rationale: When administering furosemide (Lasix), it is crucial to monitor potassium levels closely. Furosemide is a loop diuretic that can lead to potassium loss, potentially causing hypokalemia. Monitoring potassium levels helps prevent adverse effects associated with low potassium, such as cardiac arrhythmias. While monitoring sodium, calcium, and chloride levels may also be important in certain situations, potassium is the most critical to monitor when administering furosemide.

5. What test uses sound waves to create pictures of the heart, allowing doctors to see how well the heart is functioning?

Correct answer: A

Rationale: The correct answer is an echocardiogram. This test utilizes sound waves to generate images of the heart, enabling doctors to evaluate both the function and structure of the heart. Choice B, MRI, uses magnetic fields and radio waves to produce detailed images of the body's organs and structures, not specifically focused on the heart. Choice C, CT scan, employs X-rays to create detailed cross-sectional images of the body, not primarily for the heart. Choice D, X-ray, uses electromagnetic radiation to produce images of internal structures, but it does not provide the detailed pictures of the heart's function that an echocardiogram does.

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