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. What type of therapy delivers high concentrations of oxygen to the lungs?

• A. Oxygen therapy
• B. Ventilator therapy
• C. Mechanical ventilation
• D. CPAP therapy

Correct answer: A

Rationale: Oxygen therapy is the correct answer because it specifically refers to a treatment that delivers high concentrations of oxygen to the lungs. This therapy is used for patients who require additional oxygen due to conditions affecting their breathing. Ventilator therapy (B), mechanical ventilation (C), and CPAP therapy (D) involve different mechanisms and purposes than delivering high concentrations of oxygen to the lungs.

3. The client on spironolactone (Aldactone) has a potassium level of 5.8 mEq/L. What is the nurse’s priority action?

• A. Hold the spironolactone and notify the healthcare provider.
• B. Administer a potassium supplement.
• C. Continue the spironolactone as ordered.
• D. Increase the dose of spironolactone.

Correct answer: A

Rationale: With a potassium level of 5.8 mEq/L, which is high, the priority action for the nurse is to hold the spironolactone. Spironolactone is a potassium-sparing diuretic that can further increase potassium levels. Therefore, it is crucial to prevent exacerbating hyperkalemia by discontinuing the medication. Notifying the healthcare provider is necessary for further guidance and potential adjustments to the treatment plan. Administering a potassium supplement (Choice B) would be contraindicated since the client already has elevated potassium levels. Continuing the spironolactone as ordered (Choice C) can worsen hyperkalemia. Increasing the dose of spironolactone (Choice D) would be unsafe and exacerbate the high potassium levels.

4. What term describes the phenomenon wherein decreased BP causes a reflex SNS response with increased pulse, increased contractility, and vasoconstriction; and increased BP causes reflex vagal responses resulting in decreased heart rate and passive vasodilation in the systemic arterioles?

• A. Baroreflex
• B. Cheyne-Stokes breathing
• C. Frank-Starling Law
• D. Starling reflex

Correct answer: A

Rationale: The correct answer is A: Baroreflex. The Baroreflex is a mechanism by which the body maintains blood pressure homeostasis through reflexive adjustments in heart rate and vascular tone. Choice B, Cheyne-Stokes breathing, is a pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stop in breathing. Choices C and D, Frank-Starling Law and Starling reflex, are related to the intrinsic ability of the heart to adjust its output based on venous return, not specifically regulating blood pressure through reflex adjustments in heart rate and vascular tone as seen in the described phenomenon.

5. What procedure is used to remove fluid from the pleural space to help a patient breathe more easily?

• A. Thoracentesis
• B. Bronchoscopy
• C. Echocardiogram
• D. CT scan

Correct answer: A

Rationale: Thoracentesis is the correct answer. It is a procedure where a needle is inserted into the pleural space to drain fluid, relieving pressure and helping the patient breathe more easily. Bronchoscopy (choice B) is a procedure used to examine the airways, not to drain fluid. An echocardiogram (choice C) is an imaging test to assess the heart's structure and function, not related to draining pleural fluid. A CT scan (choice D) is a cross-sectional imaging test that provides detailed pictures of the inside of the body, not used for draining pleural fluid.

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