Nursing Elites

1. The client is on spironolactone (Aldactone). What is the most important dietary instruction?

• A. Avoid foods high in potassium.
• B. Increase intake of foods high in potassium.
• C. Avoid foods high in sodium.
• D. Increase intake of foods high in sodium.

Correct answer: A

Rationale: The correct answer is to avoid foods high in potassium. Spironolactone is a potassium-sparing diuretic, meaning it helps the body retain potassium and can lead to hyperkalemia if too much potassium is consumed. Choices B, C, and D are incorrect because increasing intake of potassium-rich foods can worsen hyperkalemia, while avoiding foods high in sodium is not the primary concern when taking spironolactone.

2. What is a condition where the heart's electrical system malfunctions, leading to an irregular heartbeat or arrhythmia?

• A. Arrhythmia
• B. Bradycardia
• C. Tachycardia
• D. Ventricular fibrillation

Correct answer: A

Rationale: The correct answer is A, Arrhythmia. Arrhythmia refers to an irregular heartbeat caused by the malfunction of the heart's electrical system. Bradycardia (choice B) is a condition characterized by a slow heart rate, while Tachycardia (choice C) is a condition characterized by a fast heart rate. Ventricular fibrillation (choice D) is a life-threatening arrhythmia where the heart's lower chambers quiver erratically.

3. The client on warfarin has an INR of 1.2. What is the nurse’s priority action?

• A. Increase the dose of warfarin
• B. Administer vitamin K
• C. Monitor for signs of bleeding
• D. Hold the next dose and notify the healthcare provider

Correct answer: A

Rationale: The correct answer is to increase the dose of warfarin. An INR of 1.2 is below the therapeutic range for a client on warfarin, indicating that the dose is subtherapeutic. The priority action in this situation is to adjust the dose to achieve the target therapeutic INR range (usually 2-3) to prevent thromboembolic events. Administering vitamin K is not necessary as the INR is low, and there are no signs of bleeding. Monitoring for signs of bleeding is important but not the priority in this case since the INR is subtherapeutic. Holding the next dose and notifying the healthcare provider would delay the intervention needed to adjust the dose and achieve the therapeutic range.

4. What is a severe allergic reaction that can cause difficulty breathing and shock?

• A. Anaphylaxis
• B. Asthma attack
• C. Bronchospasm
• D. Hypersensitivity

Correct answer: A

Rationale: Anaphylaxis is the correct answer. It is a severe, potentially life-threatening allergic reaction that can lead to difficulty breathing, low blood pressure, and loss of consciousness. An asthma attack is a separate condition characterized by narrowed airways and difficulty breathing, but it is not necessarily related to an allergic reaction like anaphylaxis. Bronchospasm refers to the sudden constriction of muscles in the bronchi, leading to breathing difficulties, and is not specific to allergic reactions. Hypersensitivity is a general term for an exaggerated immune response to a substance, which may or may not manifest as severe allergic reactions like anaphylaxis.

5. Which condition involves the enlargement and weakening of the left ventricle of the heart, leading to reduced pumping ability?

• A. Dilated cardiomyopathy
• B. Hypertrophic cardiomyopathy
• C. Restrictive cardiomyopathy
• D. Pericarditis

Correct answer: A

Rationale: The correct answer is A: Dilated cardiomyopathy. Dilated cardiomyopathy is characterized by the enlargement and weakening of the left ventricle of the heart, which results in a reduced ability to pump blood effectively. Choice B, Hypertrophic cardiomyopathy, involves thickening of the heart muscle, not enlargement. Choice C, Restrictive cardiomyopathy, is characterized by stiffening of the heart muscle, not enlargement. Choice D, Pericarditis, refers to inflammation of the pericardium, the lining surrounding the heart, and does not involve enlargement and weakening of the left ventricle.

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