Nursing Elites

1. The client on digoxin has a potassium level of 3.0 mEq/L. What is the nurse’s priority action?

• A. Administer a potassium supplement
• B. Hold the digoxin and notify the healthcare provider
• C. Continue the current digoxin dose
• D. Administer Digibind

Correct answer: B

Rationale: The correct answer is to hold the digoxin and notify the healthcare provider. A potassium level of 3.0 mEq/L indicates hypokalemia, which can increase the risk of digoxin toxicity. Digoxin and low potassium levels can lead to serious cardiac arrhythmias. Administering a potassium supplement (choice A) without healthcare provider guidance can worsen the situation. Continuing the current digoxin dose (choice C) can further increase the risk of toxicity. Administering Digibind (choice D) is used in severe cases of digoxin toxicity, not for addressing low potassium levels.

2. The nurse is administering enoxaparin (Lovenox) to a client. What is the most important lab value to monitor?

• A. Platelet count
• B. Hemoglobin
• C. White blood cell count
• D. aPTT

Correct answer: A

Rationale: The correct answer is A: Platelet count. When administering enoxaparin, it is crucial to monitor the platelet count because enoxaparin can lead to a rare but serious side effect known as thrombocytopenia, which is a decrease in platelet levels. Monitoring the platelet count helps in detecting this adverse effect early. Choices B, C, and D are incorrect because hemoglobin, white blood cell count, and aPTT are not the most important lab values to monitor specifically for enoxaparin administration.

3. The client on nitroglycerin patches reports dizziness when standing up. What is the nurse’s best response?

• A. Advise the client to rise slowly to prevent dizziness.
• B. Instruct the client to discontinue the nitroglycerin patches.
• C. Encourage the client to rest and avoid physical activity.
• D. Suggest the client take an over-the-counter antiemetic.

Correct answer: A

Rationale: The correct answer is to advise the client to rise slowly to prevent dizziness. Dizziness when standing up can be a sign of orthostatic hypotension, a common side effect of nitroglycerin. Rising slowly can help minimize this symptom. Instructing the client to discontinue the nitroglycerin patches (Choice B) is not appropriate without consulting a healthcare provider as sudden discontinuation can lead to adverse effects. Encouraging the client to rest and avoid physical activity (Choice C) does not address the specific issue of orthostatic hypotension. Suggesting the client take an over-the-counter antiemetic (Choice D) is not indicated for dizziness related to orthostatic hypotension.

4. The nurse is teaching a client about side effects of ACE inhibitors. What is the most important side effect to monitor?

• A. Cough
• B. Hyperkalemia
• C. Hypotension
• D. Dizziness

Correct answer: A

Rationale: The correct answer is A: Cough. ACE inhibitors commonly cause a persistent dry cough in patients. This side effect is important to monitor because it can indicate the development of angioedema, a serious adverse reaction that requires immediate medical attention. Hyperkalemia (choice B) is a potential side effect of ACE inhibitors but is not typically the most important one to monitor. Hypotension (choice C) and dizziness (choice D) are also possible side effects of ACE inhibitors, but they are not as critical to monitor as the development of a persistent cough.

5. The nurse is monitoring a client on dobutamine. What adverse effect should the nurse watch for?

• A. Tachycardia
• B. Bradycardia
• C. Hypertension
• D. Respiratory distress

Correct answer: A

Rationale: The correct answer is A: Tachycardia. Dobutamine is a medication that stimulates beta-1 adrenergic receptors in the heart, leading to increased heart rate. Therefore, tachycardia is a common adverse effect that the nurse should monitor for. Choices B, C, and D are incorrect because dobutamine typically does not cause bradycardia, hypertension, or respiratory distress as its primary adverse effects.

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