the nurse is administering a beta blocker to a client with a heart rate of 50 bpm what is the priority action
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Nursing Elites

ATI RN

Physical Exam Cardiovascular System

1. The nurse is administering a beta blocker to a client with a heart rate of 50 bpm. What is the priority action?

Correct answer: A

Rationale: The correct action is to hold the beta blocker and notify the healthcare provider. A heart rate of 50 bpm is already low, and beta blockers can further decrease the heart rate, potentially causing adverse effects like bradycardia or heart block. Administering the beta blocker as ordered (Choice B) can exacerbate the low heart rate. Decreasing the dose of the beta blocker (Choice C) may not be sufficient to address the potential harm. Monitoring the client’s heart rate and reassessing in 30 minutes (Choice D) may delay necessary interventions if the heart rate drops further. Therefore, the priority is to hold the medication and seek guidance from the healthcare provider.

2. What is the buildup of plaque in the arteries that can lead to heart attack, stroke, and other cardiovascular diseases?

Correct answer: A

Rationale: Atherosclerosis is the correct answer. It is the buildup of plaque in the arteries, leading to the narrowing of blood vessels, reduced blood flow, and an increased risk of heart attacks, strokes, and other cardiovascular diseases. Arteriosclerosis (choice B) refers to the hardening and thickening of arterial walls, while hypertension (choice C) is high blood pressure, and diabetes (choice D) is a metabolic disorder characterized by high blood sugar levels. Therefore, choices B, C, and D are incorrect in the context of the question.

3. What is an acute respiratory infection that inflames the alveoli in one or both lungs, causing them to fill with fluid or pus?

Correct answer: A

Rationale: Pneumonia is the correct answer because it is an acute respiratory infection that inflames the alveoli in one or both lungs, leading to the accumulation of fluid or pus. This condition presents with symptoms like cough, fever, and difficulty breathing. Bronchitis is the inflammation of the bronchial tubes, not the alveoli. Tuberculosis is a bacterial infection that primarily affects the lungs but does not always result in alveolar inflammation. Asthma is a chronic respiratory condition characterized by airway inflammation and narrowing, not alveolar inflammation.

4. 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.

5. The client is on digoxin and has severe digoxin toxicity. What is the nursing priority action?

Correct answer: B

Rationale: The correct answer is to give Digibind as an antidote in cases of severe digoxin toxicity. Digibind works by binding to digoxin and preventing it from causing further harm. Checking the potassium level (choice A) is important but not the priority when the client has severe toxicity. Changing the dosing to every other day (choice C) is not appropriate in the setting of severe toxicity where immediate action is required. Giving a potassium supplement (choice D) may be needed eventually, but the priority is to administer Digibind to counteract the toxic effects of digoxin.

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