Nursing Elites

1. What side effect should be monitored for in a patient with chronic heart failure taking spironolactone?

• A. Hypokalemia
• B. Hyperkalemia
• C. Hyponatremia
• D. Hypernatremia

Correct answer: B

Rationale: The correct answer is B: Hyperkalemia. Spironolactone is a potassium-sparing diuretic commonly used in patients with heart failure. One of the potential side effects of spironolactone therapy is hyperkalemia, which is an elevated level of potassium in the blood. Hyperkalemia can lead to serious cardiac arrhythmias, making it crucial for healthcare providers to monitor potassium levels closely. Choices A, C, and D are incorrect because hypokalemia (low potassium levels), hyponatremia (low sodium levels), and hypernatremia (high sodium levels) are not typically associated with spironolactone use in patients with chronic heart failure.

2. Why is morphine administered to a patient with a myocardial infarction (MI)?

• A. To reduce pain.
• B. To decrease anxiety.
• C. To reduce cardiac workload.
• D. To increase respiratory rate.

Correct answer: C

Rationale: Morphine is administered to a patient with a myocardial infarction (MI) primarily to reduce cardiac workload. By reducing preload and afterload, morphine helps improve oxygenation to the heart muscle. This decrease in workload on the heart can alleviate symptoms and reduce strain on the heart muscle during an MI. Choices A and B are incorrect because the primary goal of administering morphine in this context is not pain relief or anxiety reduction. Choice D is incorrect as morphine does not aim to increase respiratory rate but rather to address the cardiac workload.

3. The preceptor is orienting a new graduate nurse to the critical care unit. The preceptor asks the new graduate to state symptoms that most likely indicate the beginning of a shock state in a critically ill client. What findings should the new graduate nurse identify?

• A. Warm skin, hypertension, and constricted pupils.
• B. Bradycardia, hypotension, and respiratory acidosis.
• C. Mottled skin, tachypnea, and hyperactive bowel sounds.
• D. Tachycardia, mental status change, and low urine output.

Correct answer: D

Rationale: Tachycardia, mental status change, and low urine output are early indicators of shock. In a critically ill client, these findings suggest a decrease in tissue perfusion. Prompt recognition and intervention are crucial to prevent the progression of shock and its complications.

4. A client with a diagnosis of schizophrenia is being treated with risperidone (Risperdal). Which side effect should the nurse monitor for?

• A. Hypertension
• B. Weight loss
• C. Hyperactivity
• D. Hyperglycemia

Correct answer: D

Rationale: The correct answer is D: Hyperglycemia. Risperidone (Risperdal) can lead to metabolic side effects, such as hyperglycemia, which requires monitoring. Choice A, Hypertension, is incorrect because risperidone is not typically associated with hypertension. Choice B, Weight loss, is less common with risperidone use as it can lead to weight gain. Choice C, Hyperactivity, is not a common side effect of risperidone; instead, it is more known for sedative effects.

5. A client with heart failure is prescribed furosemide (Lasix). Which instruction should the nurse include in the client's teaching plan?

• A. Take the medication before bedtime.
• B. Report any weight gain of more than 2 pounds in a day.
• C. Increase your intake of high-sodium foods.
• D. Limit your fluid intake to less than 1 liter per day.

Correct answer: B

Rationale: In heart failure, fluid retention is a concern. Furosemide helps manage this by promoting diuresis. Instructing the client to report weight gain exceeding 2 pounds in a day is crucial as it can indicate fluid accumulation, prompting timely intervention to prevent worsening heart failure symptoms and complications.

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