the client on digoxin has a potassium level of 30 meql what is the nurses priority action
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Nursing Elites

ATI RN

Physical Exam Cardiovascular System

1. The client on digoxin has a potassium level of 3.0 mEq/L. What is the nurse’s priority action?

Correct answer: B

Rationale: The correct answer is to hold the digoxin and notify the healthcare provider. A potassium level of 3.0 mEq/L indicates hypokalemia, which can increase the risk of digoxin toxicity. Digoxin and low potassium levels can lead to serious cardiac arrhythmias. Administering a potassium supplement (choice A) without healthcare provider guidance can worsen the situation. Continuing the current digoxin dose (choice C) can further increase the risk of toxicity. Administering Digibind (choice D) is used in severe cases of digoxin toxicity, not for addressing low potassium levels.

2. What is a type of pneumonia that is contracted by inhaling contaminated water droplets?

Correct answer: A

Rationale: The correct answer is Legionnaires' disease. Legionnaires' disease is a severe form of pneumonia caused by inhaling water droplets contaminated with Legionella bacteria. This bacterium thrives in water systems such as air conditioning units, hot tubs, and water fountains. Choices B, C, and D are incorrect because Tuberculosis is caused by Mycobacterium tuberculosis, Asbestosis is caused by asbestos fibers, and Histoplasmosis is caused by a fungus found in bird and bat droppings.

3. The nurse is caring for a client on amiodarone. What adverse effect is the nurse most concerned about?

Correct answer: A

Rationale: The correct answer is A, Pulmonary toxicity. Amiodarone is known to cause pulmonary toxicity, which can be serious and even fatal in some cases. This adverse effect includes interstitial pneumonitis, pulmonary fibrosis, and acute respiratory distress syndrome. Monitoring for symptoms such as cough, dyspnea, and fever is crucial. Choices B, Liver toxicity, C, Thyroid dysfunction, and D, Renal dysfunction, are incorrect because while amiodarone can also affect the liver, thyroid, and kidneys, the most concerning adverse effect that requires immediate attention and monitoring is pulmonary toxicity.

4. The client is on enoxaparin (Lovenox) for DVT prophylaxis. What is the most important lab value to monitor?

Correct answer: A

Rationale: The correct answer is A: Platelet count. When a client is on enoxaparin (Lovenox), monitoring the platelet count is crucial as enoxaparin can lead to a rare but serious side effect known as heparin-induced thrombocytopenia (HIT), causing a decrease in platelet count. Monitoring the platelet count helps detect this adverse reaction early. Choices B, C, and D are incorrect because enoxaparin therapy does not directly affect PT/INR, aPTT, or hemoglobin levels.

5. What is an infection that causes inflammation in the air sacs of one or both lungs, which may fill with fluid or pus?

Correct answer: A

Rationale: The correct answer is A, Pneumonia. Pneumonia is an infection that inflames the air sacs in one or both lungs, which may fill with fluid or pus, causing symptoms like cough, fever, chills, and difficulty breathing. Tuberculosis (B) is a bacterial infection that primarily affects the lungs but is caused by a different bacterium. Pleurisy (C) is inflammation of the tissues that line the lungs and chest cavity, not the air sacs. Pulmonary edema (D) is a condition where fluid accumulates in the lungs' air sacs but is often due to heart problems rather than an infection.

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