the nurse is administering digoxin to a client with a heart rate of 45 bpm what is the nurses priority action
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Nursing Elites

ATI RN

Physical Exam Cardiovascular System

1. The nurse is administering digoxin to a client with a heart rate of 45 bpm. 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 heart rate of 45 bpm is already low, and digoxin can further decrease the heart rate, leading to serious complications like bradycardia or heart block. Administering the medication can exacerbate the bradycardia, hence it should be withheld. Increasing the dose of digoxin is contraindicated due to the client's low heart rate. Monitoring the heart rate alone without taking immediate action to withhold the medication is not the priority when faced with the risk of further lowering the heart rate.

2. What test measures the pressure in the arteries during the contraction and relaxation of the heart?

Correct answer: A

Rationale: The correct answer is 'Blood pressure test.' This test measures the pressure in the arteries during the contraction (systolic) and relaxation (diastolic) phases of the heart, providing important information about heart health. Choice B, 'Electrocardiogram (ECG or EKG),' records the heart's electrical activity and is not specifically related to measuring arterial pressure. Choice C, 'Spirometry,' assesses lung function by measuring airflow. Choice D, 'Pulse oximetry,' measures oxygen saturation in the blood, not arterial pressure.

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. What is a condition where the heart is unable to relax properly between beats, reducing its ability to fill with blood?

Correct answer: A

Rationale: The correct answer is A: Diastolic heart failure. In diastolic heart failure, the heart is unable to relax properly between beats, leading to a reduced ability to fill with blood. This condition primarily affects the heart's filling function rather than its pumping function, which is characteristic of systolic heart failure (choice B). Hypertrophic cardiomyopathy (choice C) involves the abnormal thickening of the heart muscle, while restrictive cardiomyopathy (choice D) is characterized by the heart muscle becoming stiff and less compliant. Therefore, choices B, C, and D are incorrect in the context of a heart condition where relaxation between beats is impaired.

5. Which of the following is a type of heart attack that occurs when the blood supply to part of the heart muscle is severely reduced or stopped?

Correct answer: A

Rationale: The correct answer is A: Myocardial infarction. Myocardial infarction, commonly known as a heart attack, occurs when the blood supply to part of the heart muscle is severely reduced or stopped, leading to tissue damage or death. Angina (choice B) is chest pain or discomfort that occurs when the heart muscle doesn't get enough oxygen-rich blood. Stroke (choice C) is a condition where the blood supply to the brain is interrupted or reduced. Congestive heart failure (choice D) is a chronic condition where the heart muscle doesn't pump blood as well as it should.

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