The client on digoxin has a potassium level of 2.7 mEq/L. What is the nurse's priority action?

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.

Correct Answer: A

Rationale: The correct answer is A: Hold the spironolactone and notify the healthcare provider. Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia. With a potassium level of 5.9 mEq/L, the client is at risk for serious complications like cardiac arrhythmias. The priority action is to stop the medication to prevent further elevation of potassium levels and inform the healthcare provider for further management. Administering potassium supplements (B) would worsen the hyperkalemia. Continuing spironolactone (C) or increasing the dose (D) would be inappropriate and potentially harmful in this situation.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Contractility. When a patient exhibits a decreased cardiac output (CO) with unchanged pulmonary artery wedge pressures, heart rate (HR), and systemic vascular resistance (SVR), it indicates a problem with the contractility of the heart muscle. Contractility refers to the heart's ability to contract effectively and pump blood efficiently. A decrease in contractility means the heart is not able to pump blood adequately despite normal preload (volume of blood in the heart before contraction), afterload (resistance the heart must overcome to circulate blood), and heart rate. Option A) SV (stroke volume) is not the correct answer because if stroke volume were the issue, it would likely affect preload or afterload, leading to changes in pulmonary artery wedge pressures or SVR. Option B) Preload is not the correct answer as the question states that preload is unchanged, so a decrease in preload would not explain the decreased CO. Option C) Afterload is also not the correct answer as the question specifies that afterload (SVR) is unchanged, so a decrease in afterload would not lead to a decreased CO in this case. Understanding the concept of contractility is crucial in hemodynamic monitoring to assess heart function accurately. Recognizing the impact of contractility on cardiac output helps nurses intervene appropriately to optimize patient outcomes in various clinical settings.

Correct Answer: B

Rationale: In this scenario, the correct nursing activity to accomplish first is option B) Administer sublingual nitroglycerin. This is because the patient is presenting with left anterior chest pain, which is indicative of a potential cardiac issue such as unstable angina or myocardial infarction. Nitroglycerin is a vasodilator that helps to relax and dilate blood vessels, thus reducing the workload on the heart and improving blood flow to the heart muscle. Administering nitroglycerin promptly can help alleviate chest pain and potentially prevent further damage to the heart. Option A) Auscultate heart sounds is not the priority in this situation because the patient's symptoms already suggest a cardiac issue, and immediate intervention is needed. Option C) Insert an IV catheter is important for providing medications and fluids, but it is not the initial priority when dealing with a potential cardiac emergency. Option D) Obtain a brief patient health history is valuable for gathering information about the patient's health status, but it is not the most urgent action to take when a patient is experiencing chest pain and may be having a heart-related emergency. In an educational context, it is crucial for nurses to prioritize interventions based on the patient's presenting symptoms and the potential severity of the situation. Understanding the rationale behind prioritizing certain actions in cardiac emergencies is essential for providing timely and effective care to patients experiencing chest pain. This practice exam question highlights the importance of quick decision-making and prioritization in emergency situations to optimize patient outcomes.

Correct Answer: D

Rationale: The correct answer, option D, "Assist patient with cleaning around Unna's boot," is best delegated to a nursing assistant because it involves a task that is focused on direct patient care and maintenance rather than assessment or education. Cleaning around the Unna's boot is a practical task that can be safely performed by a nursing assistant under the supervision and direction of a registered nurse. Option A, "Monitor capillary perfusion once every 8 hours," involves an assessment task that requires a higher level of clinical judgment and skill, making it more appropriate for a registered nurse to perform. Assessing capillary perfusion is crucial in evaluating the effectiveness of the treatment and detecting any complications that may arise. Option B, "Teach family members the signs of infection," requires specialized knowledge and communication skills to effectively educate others on a medical topic. This task should be handled by a healthcare professional, such as a registered nurse, who can provide accurate information and address any questions or concerns from family members. Option C, "Evaluate foot sensation and movement each shift," involves ongoing patient assessment that requires clinical knowledge to interpret findings accurately. Nursing assistants may assist with mobility and activities of daily living but may not have the training to perform detailed sensory and motor assessments. In an educational context, understanding delegation in nursing is essential for providing safe and efficient patient care. Nurses need to delegate tasks appropriately based on the complexity of the task, the competency of the team member, and the patient's condition. By delegating tasks effectively, nurses can optimize workflow, enhance patient outcomes, and promote teamwork among healthcare providers.