Nokea
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?
- A. Do nothing as this is a normal potassium level.
- B. The potassium level is low so the nurse asks for an order for potassium.
- C. The nurse asks to check the digoxin level as low potassium can increase digoxin toxicity.
- D. The nurse stops the digoxin.
Correct Answer: C
Rationale: The correct answer is C because low potassium levels can increase the risk of digoxin toxicity. Digoxin and potassium have a reciprocal relationship, so low potassium levels can lead to digoxin toxicity. Checking the digoxin level is important to monitor for toxicity.
A is incorrect because a potassium level of 2.5 is low and requires intervention. B is not the appropriate action as giving potassium without checking the digoxin levels first can worsen toxicity. D is incorrect because abruptly stopping digoxin can be harmful and should only be done under the guidance of a healthcare provider.
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The echocardiogram indicates a large thrombus in the left atrium of a patient admitted with heart failure. During the night, the patient complains of severe, sudden onset left foot pain. You note that no pulse is palpable in the left foot and that it is cold and pale. Which action should you take next?
- A. Lower the patient's left foot below heart level.
- B. Administer oxygen at 4 L/minute to the patient.
- C. Notify the patient's physician about the assessment data.
- D. Check the patient's vital signs and oximetry.
Correct Answer: C
Rationale: This likely indicates embolic occlusion, requiring immediate physician intervention.
When administering furosemide (Lasix) to a client, which lab value is most important to monitor?
- A. Potassium
- B. Sodium
- C. Calcium
- D. Chloride
Correct Answer: A
Rationale: The correct answer is A: Potassium. Furosemide is a loop diuretic that can cause potassium loss through increased urine output. Monitoring potassium levels is crucial to prevent hypokalemia, which can lead to serious cardiac arrhythmias. Sodium (B) and chloride (D) levels can also be affected by furosemide but are not as critical as potassium. Calcium (C) monitoring is not typically required when administering furosemide. By closely monitoring potassium levels, healthcare providers can prevent potential complications and ensure the safe administration of furosemide.
Which of the following nursing interventions should a nurse perform when caring for a client with congestive heart failure who has decreased cardiac output?
- A. Encourage activities that engage the Valsalva maneuver.
- B. Encourage the client to perform exercises.
- C. Assess apical heart rate before administering digitalis.
- D. Offer small, frequent feedings.
Correct Answer: C
Rationale: Digitalis therapy requires careful monitoring of heart rate to prevent toxicity and worsening cardiac output.
You are working with an experienced nursing assistant and LPN/LVN in caring for a group of patients. You have developed a nursing diagnosis of Activity Intolerance related to fatigue and chest pain for a patient who had an acute myocardial infarction 3 days ago. Which of these nursing activities included in the care plan is best delegated to the LPN/LVN?
- A. Administer nitroglycerin (Nitro-Stat) if chest discomfort occurs during patient activities.
- B. Monitor pulse, blood pressure, and oxygen saturation before and after patient ambulation.
- C. Teach the patient energy conservation techniques to decrease myocardial oxygen demand.
- D. Explain the rationale for alternating rest periods with exercise to the patient and family.
Correct Answer: B
Rationale: Monitoring vital signs is within the scope of practice for an LPN/LVN and does not require advanced assessment skills.
In an assessment for intermittent claudication, the cardiac-vascular nurse assesses for leg pain and cramping with exertion, then asks the patient:
- A. Does shortness of breath accompany the leg pain?'
- B. Does this same type of pain occur without activity?'
- C. Is the leg pain relieved by rest?'
- D. Is the leg pain relieved with elevation?'
Correct Answer: C
Rationale: Intermittent claudication pain typically resolves with rest.