the nurse is caring for a heart client on digoxin and notes a potassium level of 25 what is the appropriate priority nursing intervention the nurse is caring for a heart client on digoxin and notes a potassium level of 25 what is the appropriate priority nursing intervention
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Nursing Elites

ATI RN

Cardiovascular System Exam

1. The nurse is caring for a heart client on digoxin and notes a potassium level of 2.5. What is the appropriate priority nursing intervention?

Correct answer: C

Rationale: The correct answer is C. When caring for a client on digoxin with a low potassium level, the priority nursing intervention is to check the digoxin level. Low potassium can increase the risk of digoxin toxicity. Checking the digoxin level will help determine if any adjustments to the medication regimen are needed to prevent potential harm. Choice A is incorrect as a potassium level of 2.5 is low, not normal. Choice B is not the priority as simply giving potassium may not address the underlying issue of potential digoxin toxicity. Choice D is not the initial action to take without assessing the digoxin level first.

2. The client on amiodarone reports shortness of breath. What is the nurse’s best response?

Correct answer: A

Rationale: When a client on amiodarone reports shortness of breath, it can be indicative of pulmonary toxicity, a severe side effect associated with this medication. The nurse's priority is to notify the healthcare provider immediately to assess the situation and determine the appropriate course of action. Choice B is incorrect because shortness of breath with amiodarone should not be dismissed as a common side effect. Instructing the client to monitor symptoms at home (Choice C) may delay necessary intervention. Suggesting the client reduce physical activity (Choice D) does not address the potential serious nature of the symptom and the need for prompt evaluation.

3. Which best describes the role of surveillance in public health?

Correct answer: A

Rationale: Surveillance in public health primarily involves monitoring the spread of diseases. By tracking patterns of diseases and behaviors in populations, public health officials can identify potential outbreaks, assess the effectiveness of interventions, and make informed decisions to protect and improve community health. Surveillance is crucial for early detection, timely response, and prevention of the spread of infectious diseases and other health threats.

4. When attempting to determine a teenager's mental health resilience, what assessment question should the nurse ask that is not applicable?

Correct answer: D

Rationale: Assessing a teenager's mental health resilience involves exploring coping mechanisms, support systems, and attitudes towards seeking help. Option D is not relevant to assessing resilience but rather focuses on the comparison between seeking advice from a counselor versus the nurse, which doesn't directly gauge the teenager's resilience.

5. A 52-year-old male patient recently required surgery for the removal of a large calcium oxalate stone. To prevent further stone formation, the nurse advises against drinking?

Correct answer: B

Rationale: Tea contains oxalates, which can contribute to the formation of calcium oxalate stones; therefore, patients prone to kidney stones should avoid excessive tea consumption.

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