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 healthcare provider is monitoring a client on an ACE inhibitor. What lab value is most important to monitor?

• A. Potassium
• B. Sodium
• C. Creatinine
• D. Calcium

Correct answer: A

Rationale: The correct answer is A: Potassium. When a client is on an ACE inhibitor, it is crucial to monitor potassium levels because ACE inhibitors can lead to an increase in potassium, potentially causing hyperkalemia. Monitoring sodium levels (Choice B) is not as critical in this scenario. Creatinine levels (Choice C) are important for assessing kidney function but are not the most crucial lab value to monitor with ACE inhibitors. Calcium levels (Choice D) are not directly affected by ACE inhibitors and are not the priority for monitoring in this case.

3. What is an infection that causes inflammation in the air sacs of one or both lungs, which may fill with fluid or pus?

• A. Pneumonia
• B. Tuberculosis
• C. Pleurisy
• D. Pulmonary edema

Correct answer: A

Rationale: The correct answer is A, Pneumonia. Pneumonia is an infection that inflames the air sacs in one or both lungs, which may fill with fluid or pus, causing symptoms like cough, fever, chills, and difficulty breathing. Tuberculosis (B) is a bacterial infection that primarily affects the lungs but is caused by a different bacterium. Pleurisy (C) is inflammation of the tissues that line the lungs and chest cavity, not the air sacs. Pulmonary edema (D) is a condition where fluid accumulates in the lungs' air sacs but is often due to heart problems rather than an infection.

4. What is the condition where the heart's mitral valve does not close properly, allowing blood to leak backward into the left atrium?

• A. Mitral regurgitation
• B. Aortic stenosis
• C. Tricuspid regurgitation
• D. Pulmonary hypertension

Correct answer: A

Rationale: Mitral regurgitation is the condition where the heart's mitral valve does not close properly, allowing blood to leak backward into the left atrium. This can result in symptoms like shortness of breath and fatigue. Choices B, C, and D are incorrect because aortic stenosis, tricuspid regurgitation, and pulmonary hypertension involve different heart valves or conditions, not the mitral valve specifically.

5. The nurse is administering enoxaparin (Lovenox) to a client. What is the most important lab value to monitor?

• A. Platelet count
• B. Hemoglobin
• C. White blood cell count
• D. aPTT

Correct answer: A

Rationale: The correct answer is A: Platelet count. When administering enoxaparin, it is crucial to monitor the platelet count because enoxaparin can lead to a rare but serious side effect known as thrombocytopenia, which is a decrease in platelet levels. Monitoring the platelet count helps in detecting this adverse effect early. Choices B, C, and D are incorrect because hemoglobin, white blood cell count, and aPTT are not the most important lab values to monitor specifically for enoxaparin administration.

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