Nursing Elites

1. A client on an ACE inhibitor reports a persistent cough. What is the nurse’s best response?

• A. Reassure the client that the cough is a common side effect and is usually not serious.
• B. Instruct the client to report the cough to the healthcare provider as it may require discontinuation of the medication.
• C. Advise the client to use a humidifier at night to relieve the cough.
• D. Suggest the client take an over-the-counter cough suppressant.

Correct answer: B

Rationale: The correct answer is B. A persistent cough in a client on an ACE inhibitor may indicate a serious side effect that requires discontinuation of the medication. Instructing the client to report the cough to the healthcare provider is essential for proper evaluation and management. Choice A is incorrect because simply reassuring the client may delay necessary action. Choice C is incorrect as using a humidifier may not address the underlying cause of the cough. Choice D is incorrect because taking a cough suppressant without healthcare provider guidance may mask symptoms without addressing the cause.

2. What is a condition where the heart beats with an irregular or abnormal rhythm?

• A. Arrhythmia
• B. Hypertension
• C. Tachycardia
• D. Bradycardia

Correct answer: A

Rationale: Arrhythmia is the correct answer because it refers to an irregular or abnormal heart rhythm, which can cause the heart to beat too fast, too slow, or erratically. Hypertension (choice B) is high blood pressure and not directly related to irregular heart rhythm. Tachycardia (choice C) is a condition where the heart beats too quickly, not necessarily irregularly. Bradycardia (choice D) is a condition where the heart beats too slowly, not necessarily irregularly. Therefore, only arrhythmia (choice A) fits the description provided in the question.

3. This medication type is used to relax and widen blood vessels, improving blood flow and reducing blood pressure.

• A. Vasodilator
• B. Anticoagulant
• C. Diuretic
• D. Beta-blocker

Correct answer: A

Rationale: The correct answer is A: Vasodilator. Vasodilators are medications that work by relaxing and widening blood vessels, which improves blood flow and reduces blood pressure. They are commonly used in the treatment of heart conditions. Anticoagulants (choice B) are medications that prevent blood clot formation, diuretics (choice C) increase urine production to reduce fluid retention, and beta-blockers (choice D) reduce heart rate and workload on the heart. These mechanisms differ from the action of vasodilators.

4. The client on warfarin has an INR of 4.5. What is the most appropriate action by the nurse?

• A. Administer vitamin K.
• B. Hold the next dose of warfarin.
• C. Increase the dose of warfarin.
• D. Monitor the client’s INR closely.

Correct answer: A

Rationale: An INR of 4.5 is elevated, indicating an increased risk of bleeding due to excessive anticoagulation. The most appropriate action for the nurse in this scenario is to administer vitamin K. Vitamin K helps reverse the anticoagulant effects of warfarin, thus lowering the INR and reducing the risk of bleeding. Holding the next dose of warfarin (choice B) is not sufficient to address the immediate high INR level. Increasing the dose of warfarin (choice C) would further elevate the INR, worsening the risk of bleeding. While monitoring the client's INR closely (choice D) is important, immediate action is required to address the critically high INR level, making the administration of vitamin K the priority intervention.

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.

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