Nursing Elites

1. The client on spironolactone (Aldactone) has a potassium level of 5.6 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 5.6 mEq/L is high, indicating hyperkalemia. Spironolactone is a potassium-sparing diuretic that can further elevate potassium levels. Therefore, the priority action is to withhold the medication to prevent exacerbating hyperkalemia and notify the healthcare provider for further management. Option B is incorrect because administering potassium supplements would worsen the hyperkalemia. Option C is incorrect as continuing spironolactone can lead to a further increase in potassium levels. Option D is incorrect as increasing the dose of spironolactone would be inappropriate in the presence of elevated potassium levels.

2. What is a chronic condition where the heart is unable to pump blood efficiently, leading to fluid buildup in the lungs and other parts of the body?

• A. Heart failure
• B. Cardiomyopathy
• C. Pericarditis
• D. Aortic stenosis

Correct answer: A

Rationale: Heart failure is the correct answer. It is a chronic condition characterized by the heart's inability to pump blood efficiently, resulting in symptoms like fluid buildup in the lungs and other parts of the body, shortness of breath, fatigue, and fluid retention. Cardiomyopathy (choice B) refers to diseases of the heart muscle, but it is a broader category that includes various conditions affecting the heart muscle. Pericarditis (choice C) is the inflammation of the pericardium, the sac surrounding the heart, and aortic stenosis (choice D) is a condition where the aortic valve narrows, restricting blood flow from the heart.

3. The nurse is giving a client an IV bolus of heparin. What is the most important nursing action?

• A. Monitor the client's heart rate.
• B. Check the client's blood pressure.
• C. Check for signs of bleeding.
• D. Monitor the client's respiratory rate.

Correct answer: A

Rationale: When administering an IV bolus of heparin, the most important nursing action is to monitor the client's heart rate. Heparin can cause bradycardia as a side effect, making it crucial to assess the heart rate for any abnormalities. Checking the blood pressure (Choice B) is important but not as critical as monitoring the heart rate. While checking for signs of bleeding (Choice C) is essential, it is not the most crucial action when administering heparin. Monitoring the respiratory rate (Choice D) is also important but not as directly related to the potential side effects of heparin as monitoring the heart rate.

4. What is a condition where the airways become swollen and produce extra mucus, making it difficult to breathe, often associated with COPD?

• A. Chronic bronchitis
• B. Pneumonia
• C. Emphysema
• D. Tuberculosis

Correct answer: A

Rationale: Chronic bronchitis is the correct answer. It is a long-term inflammation of the bronchi, leading to persistent cough and mucus production, commonly associated with chronic obstructive pulmonary disease (COPD). Pneumonia (Choice B) is an infection that inflames the air sacs in one or both lungs. Emphysema (Choice C) is a lung condition where the air sacs in the lungs are damaged, making it difficult to breathe. Tuberculosis (Choice D) is a bacterial infection that primarily affects the lungs.

5. The nurse is giving the client digoxin for heart failure and recognizes that the drug has what type of effect on the heart?

• A. Negative inotropic, negative chronotropic effect
• B. Positive inotropic, negative chronotropic effect
• C. Negative inotropic, positive chronotropic effect
• D. Positive inotropic, positive chronotropic effect

Correct answer: B

Rationale: The correct answer is B: Positive inotropic, negative chronotropic effect. Digoxin strengthens the heart muscle, providing a positive inotropic effect, which increases the force of contraction. It also decreases the heart rate, having a negative chronotropic effect. Choice A is incorrect because digoxin has a positive inotropic effect, not a negative inotropic effect. Choice C is incorrect as digoxin does not have a positive chronotropic effect but a negative one. Choice D is incorrect because while digoxin has a positive inotropic effect, it does not have a positive chronotropic effect.

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