The client on digoxin has a potassium level of 3.0 mEq/L. What is the nurse's priority action?

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Physical Exam Cardiovascular System Questions

Question 1 of 5

The client on digoxin has a potassium level of 3.0 mEq/L. What is the nurse's priority action?

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.

Question 2 of 5

A client on an ACE inhibitor reports a persistent cough. What is the nurse's best response?

Correct Answer: B

Rationale: The correct answer is B because a persistent cough could indicate a serious side effect of ACE inhibitors, such as angioedema or bronchospasm. Instructing the client to report the cough to the healthcare provider is crucial to evaluate the need to discontinue the medication. Choice A is incorrect as it downplays the potential seriousness of the cough. Choice C is incorrect because a humidifier may not address the underlying cause of the cough. Choice D is incorrect because using a cough suppressant without proper evaluation can mask symptoms of a serious side effect.

Question 3 of 5

The client on spironolactone (Aldactone) has a potassium level of 5.6 mEq/L. What is the nurse's priority action?

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.

Question 4 of 5

The nurse is administering a beta blocker to a client with a heart rate of 58 bpm. What is the nurse's priority action?

Correct Answer: B

Rationale: The correct answer is B. Holding the beta blocker and notifying the healthcare provider is the priority action because a heart rate of 58 bpm may be too low to safely administer a beta blocker, which can further decrease heart rate and lead to complications like bradycardia or heart block. Increasing the dose (choice C) without assessing the current heart rate is risky. Administering the beta blocker as ordered (choice A) without considering the low heart rate is unsafe. Monitoring the client's heart rate (choice D) is important but not the priority when the initial heart rate is low.

Question 5 of 5

The client on furosemide (Lasix) is complaining of muscle cramps. What electrolyte imbalance should the nurse suspect?

Correct Answer: D

Rationale: The correct answer is D: Hypokalemia. Furosemide is a loop diuretic that causes potassium excretion, leading to low potassium levels and muscle cramps. Hypokalemia is associated with muscle weakness and cramps due to altered muscle function. Hyperkalemia (A) is high potassium levels, not typically associated with furosemide. Hyponatremia (B) is low sodium levels, not directly related to furosemide use. Hypocalcemia (C) is low calcium levels, which can cause muscle cramps but is not the most likely electrolyte imbalance with furosemide.

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