Nokea
The client on digoxin has a potassium level of 3.0 mEq/L. What is the nurse's priority action?
- A. Administer a potassium supplement
- B. Hold the digoxin and notify the healthcare provider
- C. Continue the current digoxin dose
- D. Administer Digibind
Correct Answer: B
Rationale: The correct answer is B: Hold the digoxin and notify the healthcare provider. A potassium level of 3.0 mEq/L can increase the risk of digoxin toxicity as hypokalemia potentiates its effects. Holding the digoxin and informing the healthcare provider allows for further assessment and possible adjustment of the medication regimen. Administering a potassium supplement (A) without adjusting the digoxin dose can still lead to toxicity. Continuing the current digoxin dose (C) without addressing the low potassium level puts the client at risk. Administering Digibind (D) is not necessary at this point as the priority is to address the low potassium level and prevent digoxin toxicity.
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What is the term for a blood clot blocking an artery in the lungs, leading to symptoms like shortness of breath and chest pain?
- A. Pulmonary embolism
- B. Deep vein thrombosis (DVT)
- C. Myocardial infarction
- D. Pneumothorax
Correct Answer: A
Rationale: The correct answer is A: Pulmonary embolism. A pulmonary embolism occurs when a blood clot blocks an artery in the lungs, causing symptoms like shortness of breath and chest pain. Deep vein thrombosis (B) is a blood clot in a deep vein, not in the lungs. Myocardial infarction (C) is a heart attack due to blocked blood flow to the heart muscle. Pneumothorax (D) is a collapsed lung, not related to a blood clot.
The client on nitroglycerin complains of a headache. How does the nurse explain this?
- A. This is a normal side effect of nitroglycerin.
- B. This is an allergic reaction to nitroglycerin.
- C. This is an indication of overdose.
- D. This is a sign of heart failure.
Correct Answer: A
Rationale: The correct answer is A: This is a normal side effect of nitroglycerin. Nitroglycerin is a vasodilator that relaxes blood vessels, including those in the head, leading to headaches. The nurse should explain that this is a common and expected side effect of the medication.
B: This is incorrect because a headache from nitroglycerin is not indicative of an allergic reaction.
C: This is incorrect as a headache is not typically a sign of overdose with nitroglycerin.
D: This is incorrect as a headache from nitroglycerin is not specifically linked to heart failure.
ECG changes in myocardial infarction.
- A. ST elevation
- B. Q waves
- C. Both A and B
- D. None of the above
Correct Answer: C
Rationale: ECG shows characteristic ST elevation and Q waves during MI.
What procedure involves inserting a flexible tube with a light and camera into the airways to examine the lungs and collect samples?
- A. Bronchoscopy
- B. Thoracentesis
- C. Lung biopsy
- D. Chest X-ray
Correct Answer: A
Rationale: The correct answer is A: Bronchoscopy. Bronchoscopy involves inserting a tube with a light and camera into the airways to examine the lungs and collect samples. It allows visualization of the airways, biopsy of lung tissue, and collection of samples for further analysis. Thoracentesis involves removing fluid from the pleural space, lung biopsy involves taking a tissue sample from the lung, and a chest X-ray is a radiographic imaging technique that shows the structures in the chest but does not involve direct visualization or sampling of the airways.
The client on spironolactone (Aldactone) has a potassium level of 5.6 mEq/L. What is the nurse's priority action?
- A. Hold the spironolactone and notify the healthcare provider.
- B. Administer potassium supplements.
- C. Continue the spironolactone as ordered.
- D. Increase the dose of spironolactone.
Correct Answer: A
Rationale: The correct answer is A: Hold the spironolactone and notify the healthcare provider. A potassium level of 5.6 mEq/L is elevated (normal range is 3.5-5.0 mEq/L). Spironolactone is a potassium-sparing diuretic, so the priority action is to hold the medication to prevent further elevation of potassium levels, which can lead to serious cardiac arrhythmias. Notifying the healthcare provider is crucial for further management. Administering potassium supplements (B) would further increase potassium levels. Continuing spironolactone as ordered (C) would exacerbate hyperkalemia. Increasing the dose of spironolactone (D) would be contraindicated in this situation.