Nursing Elites

1. What is the priority intervention for a patient with a suspected myocardial infarction (MI)?

• A. Administering oxygen.
• B. Administering nitroglycerin.
• C. Administering aspirin.
• D. Administering morphine.

Correct answer: A

Rationale: Administering oxygen is the priority intervention for a patient with a suspected myocardial infarction to improve oxygenation. Oxygen helps ensure an adequate oxygen supply to the heart muscle, reducing the workload on the heart. Nitroglycerin and aspirin are important interventions in the treatment of MI; however, oxygen administration takes precedence to ensure adequate oxygenation. Morphine may be considered for pain relief, but it is not the initial priority in the treatment of a suspected MI.

2. During an assessment on a patient brought to the emergency department for treatment for dehydration, the nurse notes a respiratory rate of 26 breaths/minute, a heart rate of 110 beats/minute, a blood pressure of 86/50 mm Hg, and a temperature of 39.5° C. The patient becomes dizzy when transferred from the wheelchair to a bed. The nurse observes cool, clammy skin. Which diagnosis does the nurse suspect?

• A. Fluid volume deficit (FVD)
• B. Fluid volume excess (FVE)
• C. Mild extracellular fluid (ECF) deficit
• D. Renal failure

Correct answer: A

Rationale: The nurse should suspect Fluid Volume Deficit (FVD) in this patient. Signs of FVD include elevated temperature, tachycardia, tachypnea, hypotension, orthostatic hypotension, and cool, clammy skin, which align with the patient's assessment findings. Choices B, C, and D are incorrect. Fluid Volume Excess (FVE) typically presents with bounding pulses, elevated blood pressure, dyspnea, and crackles. Mild extracellular fluid (ECF) deficit usually manifests as thirst. Renal failure commonly results in Fluid Volume Excess (FVE) rather than Fluid Volume Deficit (FVD).

3. The patient is taking hydrochlorothiazide (HydroDIURIL) and digoxin (Lanoxin). Which potential electrolyte imbalance will the nurse monitor for in this patient?

• A. Hypermagnesemia
• B. Hypernatremia
• C. Hypocalcemia
• D. Hypokalemia

Correct answer: D

Rationale: The correct answer is D: Hypokalemia. Thiazide diuretics like hydrochlorothiazide can cause hypokalemia. Hypokalemia enhances the effects of digoxin, leading to digoxin toxicity. Thiazides can also cause hypercalcemia. Choices A, B, and C are incorrect. Hypermagnesemia is not typically associated with hydrochlorothiazide use. Hypernatremia and hypocalcemia are not the primary electrolyte imbalances to monitor for in this scenario.

4. Which of the following lab values would be most concerning in a patient receiving heparin therapy?

• A. Elevated hemoglobin levels.
• B. Low platelet count.
• C. High potassium levels.
• D. Low sodium levels.

Correct answer: B

Rationale: A low platelet count is most concerning in patients receiving heparin therapy due to the risk of heparin-induced thrombocytopenia. Heparin can sometimes cause a drop in platelet count, leading to a potentially serious condition where blood does not clot as it should. This can result in excessive bleeding or clot formation in blood vessels. Elevated hemoglobin levels, high potassium levels, and low sodium levels are not typically associated with heparin therapy and are less likely to cause immediate concerns or complications in this context.

5. The client with chronic renal failure is receiving education on managing fluid intake. Which of the following statements by the client indicates a need for further teaching?

• A. I can drink as much water as I want.
• B. I should increase my intake of high-sodium foods.
• C. I can skip a dialysis session if I feel tired.
• D. I can eat whatever I want as long as I take my medications.

Correct answer: C

Rationale: Choice C is the correct answer. Clients with chronic renal failure should not skip dialysis sessions, as this can lead to serious complications. Dialysis is crucial for managing fluid and electrolyte balance in these clients. Choice A is incorrect because clients with renal failure often have fluid restrictions. Choice B is incorrect as high-sodium foods can worsen fluid retention in clients with renal failure. Choice D is incorrect because dietary restrictions are important in managing chronic renal failure, and eating whatever one wants can lead to further complications.

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