Nursing Elites

1. 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.

2. The nurse is caring for a client on digoxin with a heart rate of 48 bpm. What is the nurse’s priority action?

• A. Hold the digoxin and notify the healthcare provider.
• B. Administer the digoxin as ordered.
• C. Administer atropine to increase the heart rate.
• D. Increase the dose of digoxin.

Correct answer: A

Rationale: In this scenario, the nurse's priority action should be to hold the digoxin and notify the healthcare provider. A heart rate of 48 bpm is low, and digoxin, being a medication that can further decrease the heart rate, should be withheld. Administering the digoxin as ordered (Choice B) would not be appropriate in this situation as it can exacerbate bradycardia. Atropine (Choice C) is not the initial treatment for this scenario; holding the digoxin is the first action. Increasing the dose of digoxin (Choice D) would be contraindicated due to the client's bradycardia. Therefore, the correct action is to hold the digoxin and inform the healthcare provider for further guidance.

3. What is a severe allergic reaction that can cause difficulty breathing and shock?

• A. Anaphylaxis
• B. Asthma attack
• C. Bronchospasm
• D. Hypersensitivity

Correct answer: A

Rationale: Anaphylaxis is the correct answer. It is a severe, potentially life-threatening allergic reaction that can lead to difficulty breathing, low blood pressure, and loss of consciousness. An asthma attack is a separate condition characterized by narrowed airways and difficulty breathing, but it is not necessarily related to an allergic reaction like anaphylaxis. Bronchospasm refers to the sudden constriction of muscles in the bronchi, leading to breathing difficulties, and is not specific to allergic reactions. Hypersensitivity is a general term for an exaggerated immune response to a substance, which may or may not manifest as severe allergic reactions like anaphylaxis.

4. What is the condition where the walls of the heart's ventricles become thickened, reducing the heart's ability to pump blood effectively?

• A. Ventricular hypertrophy
• B. Atrial fibrillation
• C. Restrictive cardiomyopathy
• D. Cardiomyopathy

Correct answer: A

Rationale: Ventricular hypertrophy is the correct answer. In ventricular hypertrophy, the walls of the heart's ventricles become thickened, which decreases the heart's efficiency in pumping blood. Atrial fibrillation (choice B) is an irregular and often rapid heart rate that can lead to poor blood flow. While restrictive cardiomyopathy (choice C) involves the heart muscle becoming rigid and less compliant, it is not specifically characterized by thickening of the ventricular walls. Cardiomyopathy (choice D) is a general term for diseases of the heart muscle, which can present with various symptoms and causes.

5. The client is on digoxin and has severe digoxin toxicity. What is the nursing priority action?

• A. Check the potassium level.
• B. Give Digibind as an antidote.
• C. Change the dosing of digoxin to every other day.
• D. Administer a potassium supplement to decrease digoxin toxicity.

Correct answer: B

Rationale: The correct answer is to give Digibind as an antidote in cases of severe digoxin toxicity. Digibind works by binding to digoxin and preventing it from causing further harm. Checking the potassium level (choice A) is important but not the priority when the client has severe toxicity. Changing the dosing to every other day (choice C) is not appropriate in the setting of severe toxicity where immediate action is required. Giving a potassium supplement (choice D) may be needed eventually, but the priority is to administer Digibind to counteract the toxic effects of digoxin.

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