Nursing Elites

1. The client is on enoxaparin (Lovenox) for DVT prophylaxis. What is the most important lab value to monitor?

• A. Platelet count
• B. PT/INR
• C. aPTT
• D. Hemoglobin

Correct answer: A

Rationale: The correct answer is A: Platelet count. When a client is on enoxaparin (Lovenox), monitoring the platelet count is crucial as enoxaparin can lead to a rare but serious side effect known as heparin-induced thrombocytopenia (HIT), causing a decrease in platelet count. Monitoring the platelet count helps detect this adverse reaction early. Choices B, C, and D are incorrect because enoxaparin therapy does not directly affect PT/INR, aPTT, or hemoglobin levels.

2. Which condition is an infection that inflames the air sacs in one or both lungs, which may fill with fluid?

• A. Pneumonia
• B. Bronchitis
• C. Tuberculosis
• D. Cystic fibrosis

Correct answer: A

Rationale: The correct answer is A, Pneumonia. Pneumonia is an infection that inflames the air sacs in the lungs, which may fill with fluid or pus, causing symptoms like cough, fever, and difficulty breathing. Bronchitis (choice B) is an inflammation of the bronchial tubes, not the air sacs in the lungs. Tuberculosis (choice C) is a bacterial infection that primarily affects the lungs but does not always cause fluid accumulation in the air sacs. Cystic fibrosis (choice D) is a genetic disorder that affects the lungs but does not directly cause inflammation of the air sacs with fluid.

3. The nurse is teaching a client about the side effects of beta blockers. What is the most important side effect to monitor?

• A. Hypotension
• B. Bradycardia
• C. Hyperkalemia
• D. Tachycardia

Correct answer: A

Rationale: The most important side effect to monitor when a client is on beta blockers is hypotension. Beta blockers can cause a significant drop in blood pressure, especially at the initiation of therapy. Monitoring for hypotension is crucial to prevent complications such as dizziness, syncope, or falls. While bradycardia can also occur with beta blockers, hypotension takes precedence due to its immediate impact on perfusion. Hyperkalemia is not a common side effect of beta blockers. Tachycardia is actually a condition that beta blockers aim to treat, so it is not a side effect to monitor.

4. Which valve opens during ventricular systole and closes during ventricular diastole?

• A. Aortic valve
• B. Pulmonary valve
• C. Mitral valve
• D. Tricuspid valve

Correct answer: B

Rationale: The correct answer is B: Pulmonary valve. The pulmonary valve opens during ventricular systole to allow blood to flow from the right ventricle into the pulmonary artery. The aortic valve opens during ventricular systole to allow blood to flow from the left ventricle into the aorta. The mitral valve and tricuspid valve are atrioventricular valves that open during ventricular diastole to allow blood to flow from the atria into the ventricles.

5. A client on a beta blocker has a blood pressure of 90/60 mm Hg. What is the nurse’s priority action?

• A. Hold the beta blocker and notify the healthcare provider.
• B. Administer the beta blocker as ordered.
• C. Administer a diuretic to reduce blood pressure.
• D. Continue to monitor the client and reassess in 30 minutes.

Correct answer: A

Rationale: The correct answer is to hold the beta blocker and notify the healthcare provider. A blood pressure of 90/60 mm Hg is already low, and beta blockers can further decrease blood pressure. Administering the beta blocker can potentially worsen the situation, leading to complications. Administering a diuretic or continuing to monitor the client without taking immediate action could delay necessary intervention. Therefore, holding the beta blocker and involving the healthcare provider promptly is crucial in this scenario.

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