Nursing Elites

1. The client is on nitroglycerin patches. What should the nurse include in the client’s education?

• A. Rotate the application site with each new patch.
• B. Apply the patch at the same time each day.
• C. Leave the patch on for 24 hours, then remove it for 12 hours before applying a new one.
• D. Apply the patch to the same site each time.

Correct answer: A

Rationale: The correct answer is A: 'Rotate the application site with each new patch.' When educating a client using nitroglycerin patches, it is essential to rotate the application site to prevent skin irritation. Choice B is incorrect because applying the patch at the same time each day is not a critical aspect of patch application. Choice C is incorrect as nitroglycerin patches are usually left on for a specific period, typically 12 to 14 hours, before being replaced. Choice D is incorrect because applying the patch to the same site each time can lead to skin irritation and tolerance development.

2. What is a condition characterized by an abnormal buildup of fluid between the layers of tissue lining the lungs and chest cavity?

• A. Pleural effusion
• B. Pulmonary edema
• C. Atelectasis
• D. Sarcoidosis

Correct answer: A

Rationale: Pleural effusion is the correct answer as it refers to the accumulation of excess fluid between the layers of the pleura surrounding the lungs and chest cavity. This condition can be caused by various factors such as infections, heart failure, or cancer. Pulmonary edema (choice B) involves fluid accumulation in the lungs' air sacs and is not specific to the pleura. Atelectasis (choice C) is the collapse or closure of a lung leading to airless lung tissue and is not related to fluid buildup. Sarcoidosis (choice D) is a condition characterized by the growth of tiny collections of inflammatory cells in different parts of the body, not specifically involving fluid accumulation in the pleural space.

3. What is the term that describes the inability of cardiac cells to respond to a new stimulus while they are still in contraction from a previous stimulus?

• A. Refractoriness
• B. Excitability
• C. Contractility
• D. Automaticity

Correct answer: A

Rationale: Refractoriness is the correct term to describe the inability of cardiac cells to respond to a new stimulus while they are still in contraction from a previous stimulus. This period is essential for the heart to complete its contraction and relaxation phases without interference. Excitability refers to the ability of cells to respond to stimuli, not the inability to respond. Contractility is the force of cardiac muscle contraction, and automaticity is the ability of cardiac cells to generate electrical impulses spontaneously, which are not relevant to the described scenario.

4. What is the amount of tension the ventricle must develop during contraction to eject blood from the left ventricle into the aorta?

• A. Afterload
• B. Preload
• C. Automaticity
• D. Ejection fraction

Correct answer: A

Rationale: Afterload is the correct answer because it refers to the pressure or tension that the ventricle must overcome during systole to eject blood into the aorta. Preload, on the other hand, is the degree of stretch of the ventricular muscle at the end of diastole before it contracts. Automaticity is the ability of the heart to generate electrical impulses independently, and ejection fraction is the percentage of blood pumped out of the ventricle with each heartbeat. Therefore, in the context of the question, afterload best describes the amount of tension the ventricle must develop to eject blood into the aorta.

5. A client on spironolactone (Aldactone) has a potassium level of 6.0 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: The correct action for a client on spironolactone with a potassium level of 6.0 mEq/L is to hold the medication and notify the healthcare provider. Spironolactone is a potassium-sparing diuretic that can further elevate potassium levels, which are already high. Administering a potassium supplement (Choice B) would exacerbate the hyperkalemia. Continuing the spironolactone as ordered (Choice C) could lead to worsening hyperkalemia. Increasing the dose of spironolactone (Choice D) would be contraindicated in the presence of elevated potassium levels.

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