,NU448/NU 448 Adult Health III final
Exam | Herzing University |Q&A| 26/27
Actual (PDF)
1. A client admitted with acute decompensated heart failure has a serum potassium level of 3.1
mEq/L. Which prescribed intervention should the nurse question?
A) Initiating furosemide IV push
B) Administering digoxin 0.125 mg IV
C) Starting a nitroglycerin infusion
D) Applying supplemental oxygen
Correct Answer: Administering digoxin 0.125 mg IV
Rationale: Hypokalemia increases the risk of digoxin toxicity because digoxin and potassium compete
for binding sites on the sodium-potassium ATPase pump. A serum potassium of 3.1 mEq/L places the
client at high risk for digoxin toxicity, including life-threatening dysrhythmias. The nurse should
question the digoxin order and notify the provider. Furosemide may worsen hypokalemia but is
commonly prescribed in heart failure and requires monitoring rather than automatic questioning.
Nitroglycerin and oxygen are appropriate interventions. The priority is preventing digoxin toxicity in
the setting of hypokalemia.
2. A client with a new permanent pacemaker has a programmed rate of 70 beats/min. The nurse
notes the client's heart rate is 52 beats/min and regular. Which action should the nurse take first?
A) Assess the client's level of consciousness and blood pressure
,B) Notify the provider immediately
C) Increase the pacemaker rate
D) Administer atropine
Correct Answer: Assess the client's level of consciousness and blood pressure
Rationale: If the client's heart rate falls below the programmed rate, the first action is to assess the
client's hemodynamic status, including level of consciousness and blood pressure. If the client is
symptomatic, the nurse should notify the provider. The nurse cannot independently increase the
pacemaker rate. Atropine is administered for symptomatic bradycardia, but assessment precedes
intervention. Therefore, assessing the client's response to the bradycardia is the priority.
3. A client is admitted with infective endocarditis. Which assessment finding requires immediate
intervention?
A) A new regurgitant murmur
B) A petechial rash on the chest
C) A fever of 101.2°F
D) A blood culture positive for Staphylococcus aureus
Correct Answer: A new regurgitant murmur
Rationale: A new or changing murmur in infective endocarditis indicates valvular damage, which may
lead to acute heart failure or embolization. This requires immediate provider notification. A petechial
, rash, fever, and positive blood culture are expected findings in infective endocarditis but do not
require immediate intervention beyond ongoing treatment. Therefore, a new regurgitant murmur is
the priority finding.
4. A client with an abdominal aortic aneurysm reports sudden severe back pain and has a blood
pressure of 78/44 mm Hg. Which action should the nurse take?
A) Administer prescribed antihypertensives
B) Prepare the client for emergency surgery
C) Apply supplemental oxygen
D) Obtain a STAT abdominal ultrasound
Correct Answer: Prepare the client for emergency surgery
Rationale: Sudden severe back pain with hypotension in a client with an abdominal aortic aneurysm
indicates impending or actual rupture, which is a surgical emergency. The priority is to prepare the
client for emergency surgical repair. Administering antihypertensives would worsen the hypotension.
Supplemental oxygen may be administered but is not the priority. Obtaining an ultrasound delays
definitive treatment. Therefore, preparing for emergency surgery is the priority.
5. A client is receiving a continuous heparin infusion for a pulmonary embolism. The aPTT is 95
seconds. Which action should the nurse take?
A) Increase the infusion rate
B) Hold the infusion and notify the provider
Exam | Herzing University |Q&A| 26/27
Actual (PDF)
1. A client admitted with acute decompensated heart failure has a serum potassium level of 3.1
mEq/L. Which prescribed intervention should the nurse question?
A) Initiating furosemide IV push
B) Administering digoxin 0.125 mg IV
C) Starting a nitroglycerin infusion
D) Applying supplemental oxygen
Correct Answer: Administering digoxin 0.125 mg IV
Rationale: Hypokalemia increases the risk of digoxin toxicity because digoxin and potassium compete
for binding sites on the sodium-potassium ATPase pump. A serum potassium of 3.1 mEq/L places the
client at high risk for digoxin toxicity, including life-threatening dysrhythmias. The nurse should
question the digoxin order and notify the provider. Furosemide may worsen hypokalemia but is
commonly prescribed in heart failure and requires monitoring rather than automatic questioning.
Nitroglycerin and oxygen are appropriate interventions. The priority is preventing digoxin toxicity in
the setting of hypokalemia.
2. A client with a new permanent pacemaker has a programmed rate of 70 beats/min. The nurse
notes the client's heart rate is 52 beats/min and regular. Which action should the nurse take first?
A) Assess the client's level of consciousness and blood pressure
,B) Notify the provider immediately
C) Increase the pacemaker rate
D) Administer atropine
Correct Answer: Assess the client's level of consciousness and blood pressure
Rationale: If the client's heart rate falls below the programmed rate, the first action is to assess the
client's hemodynamic status, including level of consciousness and blood pressure. If the client is
symptomatic, the nurse should notify the provider. The nurse cannot independently increase the
pacemaker rate. Atropine is administered for symptomatic bradycardia, but assessment precedes
intervention. Therefore, assessing the client's response to the bradycardia is the priority.
3. A client is admitted with infective endocarditis. Which assessment finding requires immediate
intervention?
A) A new regurgitant murmur
B) A petechial rash on the chest
C) A fever of 101.2°F
D) A blood culture positive for Staphylococcus aureus
Correct Answer: A new regurgitant murmur
Rationale: A new or changing murmur in infective endocarditis indicates valvular damage, which may
lead to acute heart failure or embolization. This requires immediate provider notification. A petechial
, rash, fever, and positive blood culture are expected findings in infective endocarditis but do not
require immediate intervention beyond ongoing treatment. Therefore, a new regurgitant murmur is
the priority finding.
4. A client with an abdominal aortic aneurysm reports sudden severe back pain and has a blood
pressure of 78/44 mm Hg. Which action should the nurse take?
A) Administer prescribed antihypertensives
B) Prepare the client for emergency surgery
C) Apply supplemental oxygen
D) Obtain a STAT abdominal ultrasound
Correct Answer: Prepare the client for emergency surgery
Rationale: Sudden severe back pain with hypotension in a client with an abdominal aortic aneurysm
indicates impending or actual rupture, which is a surgical emergency. The priority is to prepare the
client for emergency surgical repair. Administering antihypertensives would worsen the hypotension.
Supplemental oxygen may be administered but is not the priority. Obtaining an ultrasound delays
definitive treatment. Therefore, preparing for emergency surgery is the priority.
5. A client is receiving a continuous heparin infusion for a pulmonary embolism. The aPTT is 95
seconds. Which action should the nurse take?
A) Increase the infusion rate
B) Hold the infusion and notify the provider
