the client is receiving digoxin and has a potassium level of 28 meql what is the nurses priority action
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Nursing Elites

ATI RN

Cardiovascular System Exam

1. 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.

2. A client on a beta blocker has a heart rate of 52 bpm. What is the nurse’s priority action?

Correct answer: A

Rationale: The correct answer is to hold the beta blocker and notify the healthcare provider. A heart rate of 52 bpm is low, and beta blockers can further decrease the heart rate, potentially causing harm. Therefore, withholding the medication and promptly informing the healthcare provider is crucial for further assessment and possible adjustment of the treatment plan. Administering the beta blocker as ordered (Choice B) can exacerbate the bradycardia. Increasing the dose of the beta blocker (Choice C) would further suppress the heart rate. Continuing to monitor the client and reassessing in 30 minutes (Choice D) might delay necessary interventions and increase the risk of complications in a client with a heart rate of 52 bpm.

3. What is a chronic condition where the heart muscle becomes weakened and enlarged, reducing its ability to pump blood effectively?

Correct answer: A

Rationale: Dilated cardiomyopathy is characterized by the weakening and enlargement of the heart muscle, leading to its reduced ability to pump blood effectively. This condition is different from hypertrophic cardiomyopathy, which involves abnormal thickening of the heart muscle, myocarditis, which is inflammation of the heart muscle, and pericarditis, which is inflammation of the pericardium. Therefore, the correct answer is Dilated cardiomyopathy.

4. Which of the following is a chronic condition where the heart muscle is weakened and unable to pump blood effectively, often leading to heart failure?

Correct answer: A

Rationale: Dilated cardiomyopathy is characterized by the heart muscle being weakened and unable to pump blood effectively, ultimately resulting in heart failure. Choice B, Hypertrophic cardiomyopathy, involves the heart muscle becoming abnormally thick, reducing the heart's efficiency. Choice C, Restrictive cardiomyopathy, refers to the heart becoming rigid and less able to fill with blood properly. Myocarditis, as in Choice D, is inflammation of the heart muscle usually caused by a viral infection and is different from the chronic weakening seen in dilated cardiomyopathy.

5. Which type of medication helps to reduce the workload on the heart by slowing down the heart rate?

Correct answer: A

Rationale: Beta-blockers are medications that work by blocking the action of hormones like adrenaline, thereby reducing the heart rate and the workload on the heart. This makes them effective in managing high blood pressure and various heart conditions. Calcium channel blockers work by relaxing blood vessels and reducing the heart's workload, but they do not primarily slow down the heart rate. Diuretics help the body get rid of excess salt and water by increasing urine production, which can lower blood pressure but not by slowing down the heart rate. ACE inhibitors work by relaxing blood vessels, not by directly affecting heart rate.

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