Nursing Elites

1. The nurse is preparing to administer a beta blocker to a client with hypertension. What is the priority assessment?

• 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 temperature.

Correct answer: B

Rationale: The correct answer is to check the client's blood pressure. Before administering a beta blocker to a client with hypertension, assessing the blood pressure is crucial because beta blockers can cause hypotension, potentially leading to adverse effects. Checking the heart rate may also be important but is secondary to monitoring the blood pressure in this scenario. Respiratory rate and temperature assessments are not directly related to assessing the client's response to a beta blocker in hypertension management, making choices C and D less relevant.

2. During which process does coronary artery blood flow to the myocardium occur during diastole, when coronary vascular resistance is reduced?

• A. Coronary perfusion pressure
• B. Coronary vascular resistance
• C. Diastolic filling
• D. Ventricular ejection

Correct answer: A

Rationale: The correct answer is A: Coronary perfusion pressure. Coronary perfusion pressure refers to the process of coronary artery blood flow to the myocardium during diastole when coronary vascular resistance is reduced. This process ensures that the myocardium receives sufficient oxygen and nutrients for proper functioning. Choice B, Coronary vascular resistance, is the opposite of what is described in the question. During coronary perfusion, resistance is reduced to enhance blood flow. Choices C and D, Diastolic filling and Ventricular ejection, do not directly relate to the process of coronary artery blood flow during diastole.

3. The client is receiving digoxin and has a potassium level of 2.8 mEq/L. What is the nurse’s priority action?

• A. Hold the digoxin and notify the healthcare provider.
• B. Increase the dose of digoxin.
• C. Continue the current dose of digoxin.
• D. Administer potassium supplements.

Correct answer: A

Rationale: The correct answer is to hold the digoxin and notify the healthcare provider. A potassium level of 2.8 mEq/L indicates hypokalemia, which can increase the risk of digoxin toxicity. Holding the medication and informing the healthcare provider is crucial to prevent adverse effects. Choice B is incorrect because increasing the dose of digoxin would further raise the risk of toxicity. Choice C is incorrect as continuing the current dose could exacerbate the toxicity risk. Choice D is incorrect because administering potassium supplements alone is not sufficient to address the potential digoxin toxicity; the first step should be to hold the digoxin and seek further guidance.

4. 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.

5. The client is being taught about the use of warfarin. What is the most important dietary instruction?

• A. Avoid foods high in vitamin K.
• B. Increase the intake of vitamin K-rich foods.
• C. Avoid foods high in protein.
• D. Increase the intake of foods high in calcium.

Correct answer: A

Rationale: The correct answer is A: Avoid foods high in vitamin K. Warfarin is a medication that works by decreasing the activity of vitamin K in the body to prevent blood clotting. Therefore, consuming foods high in vitamin K like green leafy vegetables can interfere with the medication's effectiveness. Choices B, C, and D are incorrect. Increasing the intake of vitamin K-rich foods would counteract the effects of warfarin. Avoiding foods high in protein or increasing the intake of foods high in calcium are not specifically related to the use of warfarin.

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