Nursing Elites

1. The client on enoxaparin (Lovenox) is scheduled for surgery. What is the nurse’s priority action?

• A. Hold the enoxaparin and notify the healthcare provider.
• B. Administer the enoxaparin as scheduled.
• C. Administer vitamin K before the surgery.
• D. Monitor the client’s INR and proceed with surgery.

Correct answer: A

Rationale: The correct answer is A: Hold the enoxaparin and notify the healthcare provider. Enoxaparin, being an anticoagulant, should be held before surgery to reduce the risk of excessive bleeding during the procedure. It is crucial to inform the healthcare provider to determine the appropriate management plan. Choice B is incorrect because administering enoxaparin before surgery can increase the risk of bleeding. Choice C is incorrect as vitamin K administration is not typically indicated in this situation. Choice D is incorrect because monitoring the client's INR and proceeding with surgery without addressing the enoxaparin can lead to significant bleeding complications.

2. What test measures the electrical activity of the heart and can detect heart rhythm problems?

• A. Electrocardiogram (ECG or EKG)
• B. Chest X-ray
• C. MRI
• D. CT scan

Correct answer: A

Rationale: The correct answer is Electrocardiogram (ECG or EKG). An electrocardiogram is a test that measures the electrical activity of the heart and can detect irregularities in heart rhythm. Choices B, C, and D are incorrect because a chest X-ray, MRI, and CT scan do not specifically measure the electrical activity of the heart or detect heart rhythm problems.

3. What type of medication is used to reduce inflammation in the airways and prevent asthma attacks?

• A. Corticosteroid
• B. Bronchodilator
• C. Antihistamine
• D. Mucolytic

Correct answer: A

Rationale: The correct answer is A, Corticosteroid. Corticosteroids are medications that work by reducing inflammation in the airways, helping to prevent asthma attacks and manage chronic respiratory conditions. Bronchodilators (choice B) work by relaxing the muscles around the airways to make breathing easier, but they do not primarily target inflammation. Antihistamines (choice C) are used to treat allergic reactions and do not directly target airway inflammation. Mucolytics (choice D) help to break down and thin mucus in the airways but do not reduce inflammation.

4. 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.

5. The client on nitroglycerin complains of a headache. What is the most appropriate response by the nurse?

• A. Administer acetaminophen as prescribed for the headache.
• B. Hold the next dose of nitroglycerin.
• C. Discontinue the nitroglycerin immediately.
• D. Notify the healthcare provider immediately.

Correct answer: A

Rationale: The correct response is to administer acetaminophen as prescribed for the headache. Headaches are a common side effect of nitroglycerin due to vasodilation. Administering acetaminophen can help relieve the headache. Holding the next dose of nitroglycerin (Choice B) may not address the current headache, and discontinuing nitroglycerin immediately (Choice C) without healthcare provider guidance can be dangerous due to the potential for rebound hypertension. Notifying the healthcare provider immediately (Choice D) is not necessary for a common side effect like a headache, and the nurse can manage this symptom independently.

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