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. Which condition is characterized by fluid collection in the lungs, making it difficult to breathe?

Correct answer: A

Rationale: The correct answer is A, Pulmonary edema. Pulmonary edema is a condition where fluid accumulates in the air sacs of the lungs, causing breathing difficulty. Pleurisy (choice B) is inflammation of the pleura causing chest pain. Pleural effusion (choice C) is the buildup of excess fluid in the pleural space, the area between the layers of tissue that line the lungs and chest cavity. Pneumothorax (choice D) is the presence of air in the pleural space, which can cause a lung to collapse.

3. Which of the following conditions is characterized by inflammation of the heart muscle, often due to a viral infection, leading to impaired heart function?

Correct answer: A

Rationale: The correct answer is A, Myocarditis. Myocarditis is an inflammation of the heart muscle, typically caused by a viral infection. It can impair the heart's ability to pump blood efficiently, potentially leading to other complications. Endocarditis (choice B) is an inflammation of the inner lining of the heart chambers and valves. Pericarditis (choice C) is inflammation of the pericardium, the outer lining of the heart. Cardiomyopathy (choice D) is a disease of the heart muscle that affects the heart's ability to pump blood.

4. What does the PR interval measure?

Correct answer: A

Rationale: The PR interval measures the time it takes for the electrical impulse to travel from the atria to the ventricles. It is crucial in diagnosing heart rhythm disorders, as abnormalities in this interval can indicate conduction abnormalities between the atria and ventricles. Choices B, C, and D are incorrect. The QRS complex represents ventricular depolarization, the QT interval represents the duration of ventricular repolarization, and the ST segment represents the time between ventricular depolarization and repolarization.

5. What is the term used to describe a condition where the blood flow to the brain is temporarily interrupted, often referred to as a 'mini-stroke'?

Correct answer: A

Rationale: The correct answer is A: Transient ischemic attack (TIA). A transient ischemic attack (TIA) is often called a 'mini-stroke' because it is characterized by a temporary interruption of blood flow to the brain, resulting in stroke-like symptoms that typically resolve within a short period. Choice B, 'Stroke,' is incorrect because a stroke involves a more prolonged interruption of blood flow, leading to lasting brain damage. Choices C and D, 'Myocardial infarction' and 'Pulmonary embolism,' are unrelated conditions involving the heart and lungs, respectively, and do not describe a temporary interruption of blood flow to the brain.

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