Nursing Elites

1. The nurse is administering a beta blocker to a client with a heart rate of 58 bpm. What is the nurse’s priority action?

• A. Administer the beta blocker as ordered.
• B. Hold the beta blocker and notify the healthcare provider.
• C. Increase the dose of the beta blocker.
• D. Monitor the client’s heart rate and reassess in 30 minutes.

Correct answer: B

Rationale: The correct answer is B. A heart rate of 58 bpm is considered low, and beta blockers can further decrease the heart rate. Therefore, the nurse's priority action should be to hold the beta blocker and notify the healthcare provider for further assessment. Choice A is incorrect because administering the beta blocker without considering the low heart rate can worsen the condition. Choice C is incorrect as increasing the dose of the beta blocker can lead to further slowing of the heart rate, which is not safe in this situation. Choice D is not the priority action; holding the medication and seeking guidance from the healthcare provider is more crucial.

2. The client has a prescription for sublingual nitroglycerin. What is the nurse's instruction for how to take this medication during an episode of chest pain?

• A. Take one tablet every 5 minutes, up to three tablets.
• B. Take one tablet every hour until the pain subsides.
• C. Take two tablets immediately if chest pain occurs.
• D. Take one tablet with a full glass of water.

Correct answer: A

Rationale: The correct answer is A. The standard instruction for sublingual nitroglycerin during an episode of chest pain is to take one tablet every 5 minutes, up to three tablets. If the pain persists after taking three tablets, the client should seek emergency help. Choice B is incorrect because taking one tablet every hour is not the appropriate dosing for acute chest pain. Choice C is incorrect as taking two tablets immediately is not in line with the recommended dosing instructions. Choice D is incorrect because sublingual nitroglycerin should be placed under the tongue, not swallowed with water.

3. 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.

4. Which term refers to the relaxation phase of the heart, during which the chambers fill with blood?

• A. Diastole
• B. Systole
• C. Refractoriness
• D. Automaticity

Correct answer: A

Rationale: The correct answer is A, Diastole. Diastole is the phase of the cardiac cycle when the heart muscles relax, allowing the chambers to fill with blood. Choice B, Systole, is incorrect as systole is the contraction phase of the heart when blood is pumped out of the chambers. Choice C, Refractoriness, refers to a period during which the heart muscle is unresponsive to stimuli. Choice D, Automaticity, relates to the heart's ability to generate its own electrical impulses.

5. The nurse is caring for a client on warfarin with an INR of 5.2. What is the most appropriate action?

• A. Administer vitamin K as an antidote.
• B. Hold the next dose of warfarin.
• C. Increase the dose of warfarin.
• D. Monitor the client’s INR closely.

Correct answer: A

Rationale: An INR of 5.2 is elevated, indicating an increased risk of bleeding. Administering vitamin K can help reverse the effects of warfarin, which is the most appropriate action in this situation. Holding the next dose of warfarin is not enough to address the high INR, and increasing the dose would further elevate the INR level. Monitoring the INR closely is important, but in this case, immediate action is needed to counteract the anticoagulant effects of warfarin.

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