ATI RN
Physical Exam Cardiovascular System
1. The nurse is administering digoxin to a client. What is the most important parameter to check before administration?
- A. Heart rate
- B. Blood pressure
- C. Respiratory rate
- D. Oxygen saturation
Correct answer: A
Rationale: The correct answer is A: Heart rate. Before administering digoxin, it is crucial to check the client's heart rate because digoxin can cause bradycardia, making it essential to ensure the heart rate is within the appropriate range. Blood pressure, respiratory rate, and oxygen saturation are also important parameters to monitor in a clinical setting, but when administering digoxin, the focus should primarily be on the heart rate due to its potential effects on cardiac function.
2. Which of the following is a chronic inflammatory disease of the airways that causes episodes of wheezing, breathlessness, chest tightness, and coughing?
- A. Asthma
- B. Bronchitis
- C. Pneumonia
- D. Emphysema
Correct answer: A
Rationale: Asthma is the correct answer. It is a chronic inflammatory disease of the airways characterized by episodes of wheezing, breathlessness, chest tightness, and coughing. These symptoms are often triggered by allergens or exercise. Bronchitis is an inflammation of the bronchial tubes, but it is not typically chronic or involve the same triggers as asthma. Pneumonia is an infection of the lungs, and emphysema is a type of chronic obstructive pulmonary disease (COPD) often caused by smoking.
3. The client is receiving digoxin and complains of nausea. What is the nurse’s priority action?
- A. Check the client’s digoxin level.
- B. Continue the current dose of digoxin.
- C. Administer an antiemetic for nausea.
- D. Discontinue the digoxin immediately.
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.
4. The nurse is caring for a client on warfarin with an INR of 1.8. What is the most appropriate action?
- A. Increase the dose of warfarin.
- B. Administer vitamin K.
- C. Hold the warfarin and notify the healthcare provider.
- D. Monitor the client’s INR closely.
Correct answer: D
Rationale: An INR of 1.8 is below the therapeutic range for a client on warfarin, indicating the need for monitoring closely to ensure that the INR levels reach the desired therapeutic range. Increasing the dose of warfarin (Choice A) without proper monitoring may lead to an increased risk of bleeding. Administering vitamin K (Choice B) is not typically recommended unless the client is experiencing major bleeding or requires rapid reversal of warfarin's effects. Holding the warfarin and notifying the healthcare provider (Choice C) may be necessary in certain situations, but the immediate action in this case should be to monitor the client's INR closely to guide further management.
5. The client is on amiodarone and reports blurred vision. What is the nurse’s best response?
- A. Reassure the client that this is a common side effect.
- B. Instruct the client to report this symptom to the healthcare provider immediately.
- C. Advise the client to stop taking the medication.
- D. Discontinue the amiodarone immediately.
Correct answer: B
Rationale: Blurred vision is a potential side effect of amiodarone. Instructing the client to report this symptom to the healthcare provider immediately is the most appropriate response. Choice A is incorrect because although blurred vision can be a common side effect of amiodarone, it should not be dismissed without further evaluation. Choice C is incorrect as advising the client to stop taking the medication without consulting the healthcare provider can be dangerous and is not the first course of action. Choice D is too drastic as discontinuing the medication should be done under the guidance of a healthcare provider after proper evaluation.
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