Nursing Elites

1. The client on spironolactone (Aldactone) has a potassium level of 5.8 mEq/L. What is the nurse’s priority action?

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

Correct answer: A

Rationale: With a potassium level of 5.8 mEq/L, which is high, the priority action for the nurse is to hold the spironolactone. Spironolactone is a potassium-sparing diuretic that can further increase potassium levels. Therefore, it is crucial to prevent exacerbating hyperkalemia by discontinuing the medication. Notifying the healthcare provider is necessary for further guidance and potential adjustments to the treatment plan. Administering a potassium supplement (Choice B) would be contraindicated since the client already has elevated potassium levels. Continuing the spironolactone as ordered (Choice C) can worsen hyperkalemia. Increasing the dose of spironolactone (Choice D) would be unsafe and exacerbate the high potassium levels.

2. The nurse is caring for a client on digoxin. What is the most important assessment before administering this medication?

• A. Check the client’s heart rate.
• B. Check the client’s blood pressure.
• C. Check the client’s respiratory rate.
• D. Check the client’s oxygen saturation.

Correct answer: A

Rationale: The correct answer is to check the client’s heart rate before administering digoxin because one of the side effects of digoxin is bradycardia. Monitoring the heart rate is crucial to assess whether the client's heart rate is within the acceptable range before giving the medication. Checking the blood pressure (Choice B), respiratory rate (Choice C), or oxygen saturation (Choice D) are important assessments in general patient care, but they are not specifically related to the administration of digoxin.

3. What is a condition characterized by an abnormal buildup of fluid between the layers of tissue lining the lungs and chest cavity?

• A. Pleural effusion
• B. Pulmonary edema
• C. Atelectasis
• D. Sarcoidosis

Correct answer: A

Rationale: Pleural effusion is the correct answer as it refers to the accumulation of excess fluid between the layers of the pleura surrounding the lungs and chest cavity. This condition can be caused by various factors such as infections, heart failure, or cancer. Pulmonary edema (choice B) involves fluid accumulation in the lungs' air sacs and is not specific to the pleura. Atelectasis (choice C) is the collapse or closure of a lung leading to airless lung tissue and is not related to fluid buildup. Sarcoidosis (choice D) is a condition characterized by the growth of tiny collections of inflammatory cells in different parts of the body, not specifically involving fluid accumulation in the pleural space.

4. Which structure serves as the major chemoreceptor of the heart?

• A. Carotid body
• B. Aortic body
• C. Vagus nerve
• D. SA node

Correct answer: A

Rationale: The correct answer is A, the carotid body. The carotid body is the major chemoreceptor of the heart responsible for detecting changes in blood oxygen, carbon dioxide, and pH levels. This specialized structure helps regulate the cardiovascular system's response to maintain appropriate oxygen levels in the blood. Choices B, C, and D are incorrect as they are not directly involved in chemoreception in the heart. The aortic body is primarily involved in blood pressure regulation, the vagus nerve is a cranial nerve responsible for parasympathetic innervation, and the SA node is known as the heart's natural pacemaker.

5. Which term describes a type of abnormal heart rhythm characterized by rapid and irregular beating of the atria?

• A. Atrial fibrillation
• B. Ventricular fibrillation
• C. Atrial flutter
• D. Sinus tachycardia

Correct answer: A

Rationale: The correct answer is Atrial fibrillation. Atrial fibrillation is indeed a type of abnormal heart rhythm characterized by rapid and irregular beating of the atria. This condition can increase the risk of stroke and heart failure. Choice B, Ventricular fibrillation, is incorrect because it refers to a life-threatening arrhythmia that occurs in the ventricles, not the atria. Choice C, Atrial flutter, is incorrect as it describes a different type of atrial arrhythmia characterized by a regular but fast heartbeat. Choice D, Sinus tachycardia, is incorrect because it is a normal increase in heart rate originating from the sinus node, not an abnormal rhythm.

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