Nursing Elites

1. The client is on nitroglycerin and reports chest pain. What is the nurse’s priority action?

• A. Administer nitroglycerin as ordered.
• B. Administer morphine as ordered.
• C. Administer aspirin as ordered.
• D. Notify the healthcare provider immediately.

Correct answer: D

Rationale: The correct answer is D: Notify the healthcare provider immediately. If a client on nitroglycerin reports chest pain, the priority action is to notify the healthcare provider immediately. This is crucial to ensure prompt reassessment of the client's condition and treatment plan. Administering nitroglycerin, morphine, or aspirin without consulting the healthcare provider first can be risky as the chest pain may indicate a need for a change in treatment or further evaluation. Administering medications without proper assessment and guidance can lead to complications and is not recommended in this scenario.

2. The client on a beta blocker has a blood pressure of 88/58 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. Increase the dose of the beta blocker.
• D. Continue to monitor the client and reassess in 30 minutes.

Correct answer: A

Rationale: The correct action for the nurse to take when a client on a beta blocker presents with a blood pressure of 88/58 mm Hg is to hold the beta blocker and notify the healthcare provider. Beta blockers can further decrease blood pressure, which is already low in this case. Administering the beta blocker as ordered (Choice B) would exacerbate the hypotension. Increasing the dose of the beta blocker (Choice C) would be inappropriate and unsafe given the low blood pressure. Continuing to monitor the client and reassessing in 30 minutes (Choice D) could lead to a delay in necessary intervention. Therefore, the priority is to hold the medication and seek guidance from the healthcare provider.

3. The client on furosemide (Lasix) is at risk for which electrolyte imbalance?

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

Correct answer: B

Rationale: The correct answer is B: Hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss, resulting in hypokalemia. This electrolyte imbalance is a significant risk associated with diuretic use. Choices A, C, and D are incorrect. Hyperkalemia (choice A) is not typically associated with furosemide use. Hyponatremia (choice C) and hypernatremia (choice D) are related to sodium levels, not potassium levels affected by furosemide.

4. What test measures the electrical activity of the heart over a period of time, typically 24 to 48 hours?

• A. Holter monitor
• B. Echocardiogram
• C. Stress test
• D. Arterial blood gas (ABG)

Correct answer: A

Rationale: The correct answer is A, Holter monitor. A Holter monitor is a portable device that records the electrical activity of the heart over a period of 24 to 48 hours. It is used to detect arrhythmias and other heart conditions. Choice B, Echocardiogram, is a test that uses sound waves to create images of the heart's structure and function, not focused on the electrical activity. Choice C, Stress test, evaluates the heart's function under stress but does not monitor electrical activity over an extended period. Choice D, Arterial blood gas (ABG), measures the levels of oxygen and carbon dioxide in the blood, unrelated to measuring the electrical activity of the heart over time.

5. Which of the following is a rare but serious condition where the pulmonary arteries become narrowed, increasing the blood pressure in the lungs?

• A. Pulmonary hypertension
• B. Pulmonary embolism
• C. Pulmonary fibrosis
• D. Aortic stenosis

Correct answer: A

Rationale: The correct answer is A, Pulmonary hypertension. Pulmonary hypertension is a rare but serious condition characterized by high blood pressure in the arteries of the lungs, which can lead to heart failure. Pulmonary embolism (choice B) involves a blockage in one of the pulmonary arteries in the lungs. Pulmonary fibrosis (choice C) is a lung disease that causes lung tissue scarring. Aortic stenosis (choice D) is a condition where the aortic valve narrows, affecting blood flow from the heart.

Similar Questions