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. What is the condition where the arteries in the brain become blocked or narrowed, leading to reduced blood flow and a potential stroke?

• A. Cerebral atherosclerosis
• B. Coronary artery disease
• C. Pulmonary embolism
• D. Peripheral artery disease

Correct answer: A

Rationale: Cerebral atherosclerosis is the correct answer. It is a condition where the arteries in the brain become blocked or narrowed due to plaque buildup, leading to reduced blood flow and an increased risk of stroke. Choice B, Coronary artery disease, specifically affects the arteries supplying blood to the heart, not the brain. Choice C, Pulmonary embolism, involves a blockage in the pulmonary artery that affects blood flow to the lungs, not the brain. Choice D, Peripheral artery disease, refers to a condition where blockages occur in arteries outside of the heart and brain, typically affecting the limbs.

3. What is the average cardiac output?

• A. Approximately 4 to 6 L per minute
• B. Approximately 4 to 8 L per minute
• C. Approximately 5 to 8 L per minute
• D. Approximately 3 to 7 L per minute

Correct answer: B

Rationale: The correct answer is B: Approximately 4 to 8 L per minute. Cardiac output is defined as the volume of blood the heart pumps per minute, typically ranging between 4 to 8 liters. Choices A, C, and D provide ranges that are either too narrow or outside the standard average values for cardiac output, making them incorrect.

4. The client on atorvastatin (Lipitor) should be advised to report which of the following symptoms?

• A. Muscle pain
• B. Headache
• C. Nausea
• D. Dizziness

Correct answer: A

Rationale: The correct answer is A: Muscle pain. Muscle pain can be a sign of rhabdomyolysis, a serious side effect of statins like atorvastatin. Rhabdomyolysis is a condition where muscle fibers break down rapidly and release their contents into the bloodstream, which can lead to kidney damage. Headache, nausea, and dizziness are not commonly associated with atorvastatin use and are less likely to indicate a serious adverse reaction compared to muscle pain.

5. 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.

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