the nurse is caring for a client on digoxin with a heart rate of 48 bpm what is the nurses priority action
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Nursing Elites

ATI RN

Cardiovascular System Exam

1. The nurse is caring for a client on digoxin with a heart rate of 48 bpm. What is the nurse’s priority action?

Correct answer: A

Rationale: In this scenario, the nurse's priority action should be to hold the digoxin and notify the healthcare provider. A heart rate of 48 bpm is low, and digoxin, being a medication that can further decrease the heart rate, should be withheld. Administering the digoxin as ordered (Choice B) would not be appropriate in this situation as it can exacerbate bradycardia. Atropine (Choice C) is not the initial treatment for this scenario; holding the digoxin is the first action. Increasing the dose of digoxin (Choice D) would be contraindicated due to the client's bradycardia. Therefore, the correct action is to hold the digoxin and inform the healthcare provider for further guidance.

2. Which surgical procedure involves removing a portion of the lung?

Correct answer: A

Rationale: A lobectomy is the surgical removal of a lobe of the lung. This procedure is commonly performed to treat conditions like lung cancer or severe lung diseases. Pneumonectomy involves removing an entire lung, making it incorrect. Tracheostomy is a surgical procedure to create an opening in the windpipe, not involving lung tissue removal. Bronchoscopy is a diagnostic procedure that allows visualization of the airways using a thin, flexible tube with a camera, not involving lung tissue removal.

3. The client on enoxaparin (Lovenox) is scheduled for surgery. What is the nurse’s priority action?

Correct answer: A

Rationale: The correct answer is A: Hold the enoxaparin and notify the healthcare provider. Enoxaparin, being an anticoagulant, should be held before surgery to reduce the risk of excessive bleeding during the procedure. It is crucial to inform the healthcare provider to determine the appropriate management plan. Choice B is incorrect because administering enoxaparin before surgery can increase the risk of bleeding. Choice C is incorrect as vitamin K administration is not typically indicated in this situation. Choice D is incorrect because monitoring the client's INR and proceeding with surgery without addressing the enoxaparin can lead to significant bleeding complications.

4. The nurse is monitoring a client on dobutamine. What adverse effect should the nurse watch for?

Correct answer: A

Rationale: The correct answer is A: Tachycardia. Dobutamine is a medication that stimulates beta-1 adrenergic receptors in the heart, leading to increased heart rate. Therefore, tachycardia is a common adverse effect that the nurse should monitor for. Choices B, C, and D are incorrect because dobutamine typically does not cause bradycardia, hypertension, or respiratory distress as its primary adverse effects.

5. What is a condition where the walls of the arteries become thickened and stiff, often due to the buildup of plaque, leading to reduced blood flow?

Correct answer: A

Rationale: Atherosclerosis is the correct answer. It is a condition characterized by the thickening and stiffening of artery walls due to plaque buildup, which restricts blood flow. Angina (choice B) is chest pain or discomfort caused by reduced blood flow to the heart. Hypertension (choice C) is high blood pressure, not directly related to arterial wall thickening. Arrhythmia (choice D) refers to irregular heart rhythms and is not specifically linked to artery wall changes like atherosclerosis.

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