Nursing Elites

1. The nurse is caring for a heart client on digoxin and notes a potassium level of 2.5. What is the appropriate priority nursing intervention?

• A. Do nothing as this is a normal potassium level.
• B. The potassium level is low so the nurse asks for an order for potassium.
• C. The nurse asks to check the digoxin level as low potassium can increase digoxin toxicity.
• D. The nurse stops the digoxin.

Correct answer: C

Rationale: The correct answer is C. When caring for a client on digoxin with a low potassium level, the priority nursing intervention is to check the digoxin level. Low potassium can increase the risk of digoxin toxicity. Checking the digoxin level will help determine if any adjustments to the medication regimen are needed to prevent potential harm. Choice A is incorrect as a potassium level of 2.5 is low, not normal. Choice B is not the priority as simply giving potassium may not address the underlying issue of potential digoxin toxicity. Choice D is not the initial action to take without assessing the digoxin level first.

2. The client on warfarin has an INR of 4.5. What is the most appropriate action by the nurse?

• A. Administer vitamin K.
• 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 4.5 is elevated, indicating an increased risk of bleeding due to excessive anticoagulation. The most appropriate action for the nurse in this scenario is to administer vitamin K. Vitamin K helps reverse the anticoagulant effects of warfarin, thus lowering the INR and reducing the risk of bleeding. Holding the next dose of warfarin (choice B) is not sufficient to address the immediate high INR level. Increasing the dose of warfarin (choice C) would further elevate the INR, worsening the risk of bleeding. While monitoring the client's INR closely (choice D) is important, immediate action is required to address the critically high INR level, making the administration of vitamin K the priority intervention.

3. What is the term for inflammation of the bronchial tubes, often leading to a persistent cough and mucus production?

• A. Bronchitis
• B. Asthma
• C. Pneumonia
• D. Cystic fibrosis

Correct answer: A

Rationale: The correct answer is 'Bronchitis.' Bronchitis refers to the inflammation of the bronchial tubes, which can be acute or chronic, leading to symptoms like coughing and increased mucus production. Choice B, 'Asthma,' is a chronic condition characterized by inflammation and narrowing of the airways, often causing wheezing and shortness of breath. Choice C, 'Pneumonia,' is an infection that inflames air sacs in one or both lungs, leading to symptoms like fever, cough, and difficulty breathing. Choice D, 'Cystic fibrosis,' is a genetic disorder that affects the lungs and digestive system, causing mucus buildup and respiratory issues.

4. Which test measures how much and how quickly you can move air out of your lungs?

• A. Spirometry
• B. Peak flow meter
• C. Lung volume test
• D. Arterial blood gas

Correct answer: A

Rationale: The correct answer is A, Spirometry. Spirometry is a common pulmonary function test that measures lung function by assessing the amount (volume) and speed (flow) of air that can be inhaled and exhaled. This test helps in diagnosing conditions like asthma, chronic obstructive pulmonary disease (COPD), and other lung diseases. Peak flow meter (choice B) measures the maximum speed at which a person can exhale air, mainly used in asthma management. Lung volume test (choice C) evaluates the total amount of air the lungs can hold. Arterial blood gas (choice D) measures the levels of oxygen and carbon dioxide in the blood, providing information on how well the lungs are functioning in gas exchange, but it does not specifically measure the amount and speed of air movement in and out of the lungs like spirometry does.

5. The client on furosemide is at risk for which electrolyte imbalance?

• A. Hypokalemia
• B. Hypernatremia
• C. Hyperkalemia
• D. Hyponatremia

Correct answer: A

Rationale: The correct answer is A: Hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss, resulting in hypokalemia. This electrolyte imbalance is a significant risk associated with the use of diuretics. Choice B, Hypernatremia, is incorrect as furosemide is not known to cause high sodium levels. Choice C, Hyperkalemia, is also incorrect as furosemide tends to cause potassium depletion rather than excess. Choice D, Hyponatremia, is not directly related to furosemide use.

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