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 is on a beta blocker for hypertension. What should the nurse monitor for?

• A. Bradycardia
• B. Tachycardia
• C. Hypertension
• D. Respiratory distress

Correct answer: A

Rationale: Corrected Rationale: When a client is on a beta blocker for hypertension, the nurse should monitor for bradycardia. Beta blockers are known to decrease heart rate, which can lead to bradycardia. Tachycardia (choice B) is unlikely as beta blockers have the opposite effect. Hypertension (choice C) is the condition being treated, not a side effect of beta blockers. Respiratory distress (choice D) is not a common effect of beta blockers and is not typically monitored in clients taking beta blockers.

3. The client on spironolactone should avoid which of the following?

• A. Foods high in potassium
• B. Foods high in sodium
• C. Foods high in calcium
• D. Foods high in chloride

Correct answer: A

Rationale: The correct answer is A: Foods high in potassium. Spironolactone is a potassium-sparing diuretic, meaning it helps the body retain potassium and excrete sodium. Consuming foods high in potassium while on spironolactone can lead to an excess of potassium in the body, potentially causing hyperkalemia. Choices B, C, and D are incorrect because spironolactone does not directly interact with sodium, calcium, or chloride in a way that would require specific dietary restrictions related to these minerals.

4. The client on spironolactone (Aldactone) should avoid which type of food?

• A. Foods high in potassium
• B. Foods high in sodium
• C. Foods high in calcium
• D. Foods high in chloride

Correct answer: A

Rationale: The correct answer is A: Foods high in potassium. Spironolactone is a potassium-sparing diuretic, meaning it helps the body retain potassium and excrete sodium. Therefore, clients on spironolactone should avoid foods high in potassium to prevent hyperkalemia, which is an elevated level of potassium in the blood. Choices B, C, and D are incorrect because spironolactone specifically affects potassium levels, not sodium, calcium, or chloride.

5. When administering enoxaparin (Lovenox) to a client 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 administering enoxaparin (Lovenox) for DVT prophylaxis, it is crucial to monitor the platelet count as enoxaparin can lead to thrombocytopenia, a decrease in platelet levels. Monitoring the platelet count helps in early detection of this potential adverse effect. Choices B, C, and D are incorrect because PT/INR, aPTT, and hemoglobin levels are not the most important lab values to monitor specifically for enoxaparin administration and DVT prophylaxis.

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