Nursing Elites

1. The client on spironolactone (Aldactone) has a potassium level of 5.6 mEq/L. What is the nurse’s priority action?

• A. Hold the spironolactone and notify the healthcare provider.
• B. Administer potassium supplements.
• C. Continue the spironolactone as ordered.
• D. Increase the dose of spironolactone.

Correct answer: A

Rationale: The correct answer is A: Hold the spironolactone and notify the healthcare provider. A potassium level of 5.6 mEq/L is high, indicating hyperkalemia. Spironolactone is a potassium-sparing diuretic that can further elevate potassium levels. Therefore, the priority action is to withhold the medication to prevent exacerbating hyperkalemia and notify the healthcare provider for further management. Option B is incorrect because administering potassium supplements would worsen the hyperkalemia. Option C is incorrect as continuing spironolactone can lead to a further increase in potassium levels. Option D is incorrect as increasing the dose of spironolactone would be inappropriate in the presence of elevated potassium levels.

2. When administering enoxaparin (Lovenox) to a client, what is the most important lab value to monitor?

• A. Platelet count
• B. aPTT
• C. Hemoglobin
• D. INR

Correct answer: A

Rationale: The correct answer is A: Platelet count. When administering enoxaparin (Lovenox), it is crucial to monitor the platelet count because enoxaparin can cause a rare but serious side effect known as heparin-induced thrombocytopenia, which is a decrease in platelet count that can lead to increased risk of bleeding. Monitoring the platelet count allows for early detection of this potential complication. Choices B, C, and D are incorrect because aPTT, Hemoglobin, and INR are not the most important lab values to monitor specifically when administering enoxaparin.

3. Identify the three layers of the heart:

• A. Endocardium, Myocardium, Epicardium
• B. Epicardium, Pericardium, Endocardium
• C. Myocardium, Endocardium, Pericardium
• D. Pericardium, Myocardium, Endocardium

Correct answer: A

Rationale: The correct answer is A: Endocardium, Myocardium, Epicardium. The heart consists of three main layers: the endocardium, which lines the inner chambers of the heart; the myocardium, the middle layer responsible for the heart's pumping action; and the epicardium, the outermost layer that protects the heart. Choices B, C, and D are incorrect as they do not list the heart's layers in the correct order or combination.

4. In cases of myocardial infarction leading to shock, which medication is appropriate to counteract shock?

• A. Atropine
• B. Dopamine
• C. Digoxin
• D. Adenosine

Correct answer: B

Rationale: In cases of myocardial infarction leading to shock, dopamine is the drug of choice. Dopamine helps increase blood pressure and improve blood flow to vital organs, making it beneficial in managing shock. Atropine is mainly used for symptomatic bradycardia, not for shock. Digoxin is a cardiac glycoside used in heart failure and atrial fibrillation, not for managing shock. Adenosine is typically used for diagnosing and treating supraventricular tachycardias, not for shock associated with myocardial infarction.

5. What is a type of medication that helps to prevent blood clots by thinning the blood?

• A. Anticoagulant
• B. Beta-blocker
• C. ACE inhibitor
• D. Calcium channel blocker

Correct answer: A

Rationale: Anticoagulants are medications specifically designed to prevent blood clots by thinning the blood. They work by interfering with the body's blood clotting process. Beta-blockers, ACE inhibitors, and calcium channel blockers are medications used for different purposes such as managing blood pressure, heart conditions, and regulating heart rhythm, respectively. However, they do not have the primary function of preventing blood clots like anticoagulants.

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