Nursing Elites

1. The client is receiving intravenous dopamine. What is the most important nursing assessment?

• A. Monitor heart rate and rhythm
• B. Monitor blood pressure
• C. Monitor respiratory rate
• D. Monitor oxygen saturation

Correct answer: A

Rationale: The correct answer is to monitor heart rate and rhythm when a client is receiving intravenous dopamine. Dopamine is known to potentially cause arrhythmias, making this assessment crucial. While monitoring blood pressure, respiratory rate, and oxygen saturation are important nursing assessments, they are not the most critical when dopamine is being administered.

2. What is the condition where the lungs become filled with fluid, often due to heart failure, making it difficult to breathe?

• A. Pulmonary edema
• B. Pleural effusion
• C. Pulmonary hypertension
• D. Pneumothorax

Correct answer: A

Rationale: Pulmonary edema is the correct answer. It occurs when fluid fills the lungs, usually due to heart failure, leading to breathing difficulties. Pleural effusion is the accumulation of fluid around the lungs, not inside. Pulmonary hypertension is high blood pressure in the arteries of the lungs, and pneumothorax is the presence of air between the lung and chest wall.

3. When administering an ACE inhibitor to a client with heart failure, what is the expected outcome of this medication?

• A. Decreased blood pressure
• B. Increased heart rate
• C. Increased cardiac output
• D. Decreased heart rate

Correct answer: C

Rationale: The correct answer is C: Increased cardiac output. ACE inhibitors are commonly used in heart failure to reduce the workload on the heart by decreasing blood pressure and increasing cardiac output. This ultimately helps improve the heart's efficiency and function. Choice A is incorrect because ACE inhibitors generally lead to a reduction in blood pressure. Choice B is incorrect as ACE inhibitors do not increase heart rate. Choice D is incorrect as ACE inhibitors do not typically decrease heart rate in the context of heart failure.

4. Where is the impulse from the SA node delayed, enabling atrial contraction to complete before the ventricles are stimulated and contract?

• A. AV node
• B. Bundle of His
• C. SA node
• D. Aorta

Correct answer: A

Rationale: The correct answer is AV node. The AV node is responsible for delaying the impulse from the SA node, allowing the atria to contract before the ventricles. This delay ensures the effective pumping of blood in a coordinated manner. Choices B, C, and D are incorrect because the Bundle of His is responsible for transmitting the impulse to the Purkinje fibers, the SA node is the pacemaker of the heart responsible for initiating the heartbeat, and the aorta is the main artery carrying oxygenated blood from the heart to the body, respectively, none of which are involved in delaying the impulse to allow atrial contraction before ventricular contraction.

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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