Nokea
The client on digoxin has a potassium level of 2.7 mEq/L. What is the nurse's priority action?
- A. Hold the digoxin and notify the healthcare provider.
- B. Administer the digoxin as ordered.
- C. Increase the dose of digoxin.
- D. Administer potassium supplements.
Correct Answer: A
Rationale: The correct answer is A: Hold the digoxin and notify the healthcare provider. A potassium level of 2.7 mEq/L is below the normal range (3.5-5.0 mEq/L), which can increase the risk of digoxin toxicity. Holding the digoxin and informing the healthcare provider is crucial to prevent potential harm. Administering the digoxin (choice B) can exacerbate toxicity symptoms. Increasing the dose of digoxin (choice C) is contraindicated due to the low potassium level. Administering potassium supplements (choice D) may be necessary, but the priority is to address the digoxin therapy first.
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This heart condition is characterized by decreased cardiac output and tissue perfusion, which can lead to organ failure.
- A. Cardiogenic shock
- B. Myocardial infarction
- C. Endocarditis
- D. Pericarditis
Correct Answer: A
Rationale: The correct answer is A: Cardiogenic shock. Cardiogenic shock is characterized by decreased cardiac output and tissue perfusion due to the heart's inability to pump effectively, leading to organ failure. This condition is a result of heart failure or myocardial infarction. Myocardial infarction (choice B) is a cause of cardiogenic shock, but not the specific condition described. Endocarditis (choice C) and pericarditis (choice D) do not directly result in decreased cardiac output and tissue perfusion leading to organ failure like cardiogenic shock does.
In the patient with chest pain, which results can differentiate unstable angina from an MI?
- A. ECG changes present at the onset of the pain
- B. A chest x-ray indicating left ventricular hypertrophy
- C. Appearance of troponin in the blood 48 hours after the infarct
- D. Creatine kinase (CK)-MB enzyme elevations that peak 18 hours after the infarct
Correct Answer: A
Rationale: ECG changes distinguish unstable angina from MI.
The nurse is giving a client an IV bolus of heparin. What is the most important nursing action?
- A. Monitor the client's heart rate.
- B. Check the client's blood pressure.
- C. Check for signs of bleeding.
- D. Monitor the client's respiratory rate.
Correct Answer: A
Rationale: The correct answer is A: Monitor the client's heart rate. When administering an IV bolus of heparin, it is crucial to monitor the client's heart rate because heparin can cause serious side effects such as bleeding and heparin-induced thrombocytopenia, which can lead to changes in heart rate. Checking blood pressure (B) is also important but not as critical as monitoring heart rate. Checking for signs of bleeding (C) is necessary but should be done after monitoring the heart rate. Monitoring the client's respiratory rate (D) is not directly related to heparin administration.
The nurse is encouraging a sedentary patient with major risks for CAD to perform physical exercise on a regular basis. In addition to decreasing the risk factor of physical inactivity, the nurse tells the patient that exercise will also directly contribute to reducing which risk factors?
- A. Hyperlipidemia and obesity
- B. Diabetes mellitus and hypertension
- C. Elevated serum lipids and stressful lifestyle
- D. Hypertension and elevated serum homocysteine
Correct Answer: A
Rationale: Exercise improves lipid profiles and reduces obesity.
During hemodynamic monitoring, the nurse finds that the patient has a decreased CO with unchanged pulmonary artery wedge pressures, HR, and SVR. The nurse identifies that the patient has a decrease in
- A. SV
- B. Preload
- C. Afterload
- D. Contractility
Correct Answer: D
Rationale: CO is dependent on the heart rate and stroke volume, and stroke volume is determined by preload, afterload and contractility. If CO is decreased and heart rate is unchanged, stroke volume is the variable factor.