Nursing Elites

1. A client on a beta blocker has a heart rate of 52 bpm. 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 answer is to hold the beta blocker and notify the healthcare provider. A heart rate of 52 bpm is low, and beta blockers can further decrease the heart rate, potentially causing harm. Therefore, withholding the medication and promptly informing the healthcare provider is crucial for further assessment and possible adjustment of the treatment plan. Administering the beta blocker as ordered (Choice B) can exacerbate the bradycardia. Increasing the dose of the beta blocker (Choice C) would further suppress the heart rate. Continuing to monitor the client and reassessing in 30 minutes (Choice D) might delay necessary interventions and increase the risk of complications in a client with a heart rate of 52 bpm.

2. What is the condition where the lungs become filled with fluid, often due to heart failure, making it difficult to breathe?

• A. Pulmonary edema
• B. Pleural effusion
• C. Pulmonary hypertension
• D. Pneumothorax

Correct answer: A

Rationale: Pulmonary edema is the correct answer. It occurs when fluid fills the lungs, usually due to heart failure, leading to breathing difficulties. Pleural effusion is the accumulation of fluid around the lungs, not inside. Pulmonary hypertension is high blood pressure in the arteries of the lungs, and pneumothorax is the presence of air between the lung and chest wall.

3. What is a blood clot that forms in a vein, often in the legs, and can cause serious complications if it travels to the lungs?

• A. Deep vein thrombosis (DVT)
• B. Pulmonary embolism
• C. Varicose veins
• D. Atherosclerosis

Correct answer: A

Rationale: The correct answer is Deep vein thrombosis (DVT). DVT is a blood clot that forms in a deep vein, typically in the legs, and can lead to serious complications if it breaks loose and travels to the lungs, causing a pulmonary embolism. Varicose veins (choice C) are enlarged, twisted veins usually found in the legs but are not related to blood clots. Atherosclerosis (choice D) is a condition where arteries become narrowed and hardened due to a buildup of plaque, not directly related to blood clots.

4. What is a condition where blood clots form in the deep veins, usually in the legs, and can travel to the lungs, causing serious complications?

• A. Deep vein thrombosis (DVT)
• B. Pulmonary embolism
• C. Varicose veins
• D. Peripheral artery disease

Correct answer: A

Rationale: The correct answer is A, Deep vein thrombosis (DVT). Deep vein thrombosis occurs when blood clots form in the deep veins, usually in the legs, and these clots can potentially travel to the lungs, leading to a pulmonary embolism. Pulmonary embolism (choice B) is a serious complication that can result from untreated DVT. Varicose veins (choice C) and peripheral artery disease (choice D) are not directly related to the formation of blood clots in deep veins that can lead to pulmonary embolism.

5. The client is on spironolactone (Aldactone) and has a potassium level of 5.9 mEq/L. What is the nurse’s priority action?

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

Correct answer: A

Rationale: The correct answer is A: Hold the spironolactone and notify the healthcare provider. A potassium level of 5.9 mEq/L is high, indicating hyperkalemia. Spironolactone is a potassium-sparing diuretic that can further increase potassium levels. Therefore, the priority action is to hold the medication to prevent exacerbating hyperkalemia and notify the healthcare provider for further guidance. Choice B is incorrect because administering potassium supplements would worsen hyperkalemia. Choice C is incorrect because continuing spironolactone could lead to a further increase in potassium levels. Choice D is incorrect because increasing the dose of spironolactone would exacerbate the hyperkalemia.

Similar Questions