ATI RN
Physical Exam Cardiovascular System Questions
Question 1 of 5
The nurse is administering digoxin to a client. What is the most important parameter to check before administration?
Correct Answer: A
Rationale: The correct answer is A: Heart rate. Before administering digoxin, it is crucial to check the client's heart rate because digoxin is a medication that affects the heart. Monitoring the heart rate helps assess the client's cardiac function and determines if the medication can be safely given. Checking heart rate ensures that the client is not at risk for potential adverse effects such as bradycardia or arrhythmias. Blood pressure (B), respiratory rate (C), and oxygen saturation (D) are important parameters to monitor but are not as directly related to the action of digoxin on the heart.
Question 2 of 5
The client is prescribed warfarin. What should the client be taught about this medication?
Correct Answer: A
Rationale: The correct answer is A: Avoid foods high in vitamin K. Warfarin is an anticoagulant that works by decreasing the blood's ability to clot. Vitamin K is essential for blood clotting, so consuming foods high in vitamin K can interfere with the medication's effectiveness. It is important for the client to maintain a consistent intake of vitamin K to ensure the medication works properly. Choices B, C, and D are incorrect because taking warfarin with food, at the same time daily, or increasing the dose if a dose is missed can result in adverse effects or reduced effectiveness of the medication.
Question 3 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 4 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 5 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.