Nursing Elites

1. A client with a diagnosis of acute myocardial infarction (MI) is receiving thrombolytic therapy. The nurse monitors the client for which potential complication associated with this therapy?

• A. Hypertension
• B. Bleeding
• C. Hyperkalemia
• D. Hypoglycemia

Correct answer: B

Rationale: Thrombolytic therapy is associated with an increased risk of bleeding due to its mechanism of action in dissolving blood clots. Therefore, the nurse should closely monitor the client for any signs of hemorrhage, such as unexplained bruising, bleeding gums, or blood in the urine or stools. Hypertension is not a common complication of thrombolytic therapy. Hyperkalemia and hypoglycemia are also not typically associated with this therapy.

2. A client is admitted to the emergency department with a suspected myocardial infarction (MI). The nurse should prepare the client for which immediate diagnostic test?

• A. Chest x-ray
• B. Electrocardiogram (ECG)
• C. Echocardiogram
• D. Coronary angiography

Correct answer: B

Rationale: An Electrocardiogram (ECG) is the most immediate and essential test to diagnose a myocardial infarction (MI) and assess the extent of heart damage. An ECG can quickly identify changes in the heart's electrical activity, allowing prompt initiation of appropriate interventions. A chest x-ray (Choice A) may show other conditions affecting the heart, but it is not the immediate test of choice for diagnosing an MI. An echocardiogram (Choice C) and coronary angiography (Choice D) are valuable in further assessing cardiac function and anatomy post-MI but are not the first-line diagnostic tests due to their time-consuming nature compared to an ECG.

3. The nurse is preparing to administer an intravenous dose of furosemide (Lasix) to a client with heart failure. The nurse should monitor for which potential side effect?

• A. Hypertension
• B. Hyperkalemia
• C. Hypokalemia
• D. Hypoglycemia

Correct answer: C

Rationale: Furosemide is a loop diuretic that works by promoting the excretion of water and electrolytes, including potassium. This loss of potassium can lead to hypokalemia, which can be a potential side effect of furosemide administration. Hypokalemia can result in cardiac dysrhythmias and other complications, especially in clients with heart failure who may already have compromised cardiac function. Therefore, monitoring for signs of hypokalemia, such as muscle weakness, cardiac irregularities, and fatigue, is essential when administering furosemide. Choice A, hypertension, is incorrect because furosemide is actually used to treat hypertension by reducing excess fluid in the body. Choice B, hyperkalemia, is incorrect as furosemide causes potassium loss, leading to hypokalemia. Choice D, hypoglycemia, is unrelated to the mechanism of action of furosemide and is not a common side effect associated with its administration.

4. The client is receiving digoxin (Lanoxin) for heart failure. Which symptom would indicate digoxin toxicity?

• A. Increased appetite
• B. Yellow or blurred vision
• C. Increased urination
• D. Diarrhea

Correct answer: B

Rationale: Yellow or blurred vision can be a sign of digoxin toxicity. These visual disturbances are concerning as they indicate a potential adverse reaction to the medication. Recognizing this symptom promptly is crucial to prevent serious complications. Increased appetite, increased urination, and diarrhea are not typically associated with digoxin toxicity. Therefore, option B is the correct choice in this scenario.

5. A client is admitted with coronary artery disease (CAD) and reports dyspnea at rest. What is the nurse's priority intervention?

• A. Elevate the head of the bed.
• B. Administer oxygen.
• C. Perform continuous ECG monitoring.
• D. Apply a nasal cannula.

Correct answer: A

Rationale: The nurse's priority intervention for a client with coronary artery disease (CAD) experiencing dyspnea at rest is to elevate the head of the bed. Elevating the head of the bed helps improve lung expansion and reduces the workload on the heart, aiding in respiratory effort and cardiac function. This intervention is crucial in enhancing oxygenation and optimizing cardiac output in individuals with CAD presenting with dyspnea. Administering oxygen (Choice B) is important but elevating the head of the bed takes precedence as it directly addresses the client's respiratory distress. Continuous ECG monitoring (Choice C) and applying a nasal cannula (Choice D) are relevant interventions but not the priority when a client with CAD reports dyspnea at rest.

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