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The nurse is caring for a client on digoxin with a heart rate of 48 bpm. What is the nurse's priority action?
- A. Hold the digoxin and notify the healthcare provider.
- B. Administer the digoxin as ordered.
- C. Administer atropine to increase the heart rate.
- D. Increase the dose of digoxin.
Correct Answer: A
Rationale: The correct answer is A: Hold the digoxin and notify the healthcare provider. A heart rate of 48 bpm is below the normal range, indicating bradycardia, a potential side effect of digoxin toxicity. Holding the medication and informing the healthcare provider is crucial to prevent further harm. Administering the digoxin (B) can worsen the bradycardia. Atropine (C) is not the first-line treatment for digoxin-induced bradycardia. Increasing the dose of digoxin (D) can exacerbate toxicity. Overall, prompt action to address the underlying cause is essential in this situation.
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The client on atorvastatin (Lipitor) should be advised to report which of the following symptoms?
- A. Muscle pain
- B. Headache
- C. Nausea
- D. Dizziness
Correct Answer: A
Rationale: The correct answer is A: Muscle pain. Atorvastatin can cause muscle pain as a side effect, which may progress to a serious condition called rhabdomyolysis. This requires immediate medical attention. Headache, nausea, and dizziness are less common side effects of atorvastatin and generally not as serious as muscle pain in this context. Reporting muscle pain promptly can help prevent complications and ensure appropriate management.
What condition involves the heart's electrical system malfunctioning, causing very fast heartbeats originating from the ventricles?
- A. Ventricular tachycardia
- B. Atrial fibrillation
- C. Supraventricular tachycardia
- D. Bradycardia
Correct Answer: A
Rationale: The correct answer is A: Ventricular tachycardia. Ventricular tachycardia is characterized by rapid heartbeats originating from the ventricles, resulting in an abnormal heart rhythm. This condition can be life-threatening if not promptly treated. Atrial fibrillation involves rapid, irregular heartbeats originating from the atria, not the ventricles (B). Supraventricular tachycardia also originates above the ventricles and is not specific to ventricular malfunction (C). Bradycardia, on the other hand, is a condition characterized by an abnormally slow heart rate, which is the opposite of the fast heartbeats seen in ventricular tachycardia (D).
Which structure serves as the normal pacemaker of the heart?
- A. SA node
- B. AV node
- C. Purkinje fibers
- D. Atria
Correct Answer: A
Rationale: The correct answer is A: SA node. The SA node is known as the natural pacemaker of the heart because it initiates the electrical impulses that regulate the heartbeat. It is located in the right atrium and generates the electrical signals that coordinate the heart's contractions. The other choices, B: AV node, C: Purkinje fibers, and D: Atria, do play roles in the heart's electrical conduction system, but they do not serve as the primary pacemaker. The AV node delays the electrical impulses, the Purkinje fibers distribute the impulses to the heart muscles, and the atria contract to pump blood into the ventricles. However, none of these structures serve as the primary pacemaker like the SA node does.
The client on spironolactone (Aldactone) has a potassium level of 5.8 mEq/L. What is the nurse's priority action?
- A. Hold the spironolactone and notify the healthcare provider.
- B. Administer a potassium supplement.
- 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. The priority action is to stop the medication and inform the healthcare provider because a potassium level of 5.8 mEq/L is above the normal range (3.5-5.0 mEq/L), indicating hyperkalemia. Spironolactone is a potassium-sparing diuretic that can further increase potassium levels. Continuing the medication or administering a potassium supplement would exacerbate the issue. Increasing the dose of spironolactone would be unsafe and could lead to severe complications. Therefore, holding the medication and seeking guidance from the healthcare provider is crucial in managing the client's elevated potassium level.
To assess whether Mr. Young's synchronous pacemaker is working properly, which statement do you need to remember about a synchronous pacemaker?
- A. His pacemaker will fire regardless of Mr. Young's own spontaneous heart rate
- B. His pacemaker will fire only when his own heart rate drops below 72 beats per minute
- C. If his pacemaker does not fire 72 times every minute, it is not working properly
- D. This type of pacemaker can precipitate ventricular fibrillation because of its increased chance of firing on the T wave
Correct Answer: B
Rationale: Demand pacemakers fire only when needed.