Nursing Elites

1. The nurse is giving nitroglycerin sublingually for chest pain. What is the most important instruction to give to the client?

• A. Place the tablet under the tongue and let it dissolve completely.
• B. Swallow the tablet whole with a glass of water.
• C. Chew the tablet and then swallow it.
• D. Take one tablet every 5 minutes until pain is relieved.

Correct answer: A

Rationale: The correct answer is A. The tablet should be placed under the tongue and allowed to dissolve completely to ensure rapid absorption. This route of administration allows the medication to be quickly absorbed into the bloodstream. Choice B is incorrect because nitroglycerin is meant to be absorbed sublingually, not swallowed. Choice C is incorrect as chewing the tablet can cause the medication to be rapidly absorbed, leading to adverse effects like a drop in blood pressure. Choice D is incorrect because the client should take only one tablet every 5 minutes up to a maximum of three tablets for chest pain relief.

2. What condition is characterized by the inflammation of the pleura, causing sharp chest pain that worsens with breathing?

• A. Pleurisy
• B. Pericarditis
• C. Endocarditis
• D. Myocarditis

Correct answer: A

Rationale: The correct answer is Pleurisy. Pleurisy is the inflammation of the pleura, the lining surrounding the lungs, which causes sharp chest pain that worsens with breathing. Pericarditis (choice B) is the inflammation of the pericardium, the sac around the heart, which typically causes chest pain that worsens when lying down. Endocarditis (choice C) is the inflammation of the inner lining of the heart chambers and valves, leading to symptoms like fever, fatigue, and abnormal heart sounds. Myocarditis (choice D) is inflammation of the heart muscle, which can cause symptoms such as chest pain, fatigue, and shortness of breath.

3. What test measures the oxygen level in the blood, often used to monitor patients with respiratory or cardiovascular conditions?

• A. Pulse oximetry
• B. Arterial blood gas (ABG)
• C. Echocardiogram
• D. Chest X-ray

Correct answer: A

Rationale: The correct answer is A, Pulse oximetry. Pulse oximetry is a non-invasive test that measures the oxygen saturation level in the blood, commonly used to monitor respiratory and cardiovascular health. Arterial blood gas (ABG) measures the levels of oxygen and carbon dioxide in the blood, providing more detailed information than pulse oximetry. Echocardiogram is an ultrasound test used to visualize the heart's structure and function, while a chest X-ray is used to visualize the structures in the chest, such as the heart, lungs, and bones.

4. The client is being taught about the use of warfarin. What is the most important dietary instruction?

• A. Avoid foods high in vitamin K.
• B. Increase the intake of vitamin K-rich foods.
• C. Avoid foods high in protein.
• D. Increase the intake of foods high in calcium.

Correct answer: A

Rationale: The correct answer is A: Avoid foods high in vitamin K. Warfarin is a medication that works by decreasing the activity of vitamin K in the body to prevent blood clotting. Therefore, consuming foods high in vitamin K like green leafy vegetables can interfere with the medication's effectiveness. Choices B, C, and D are incorrect. Increasing the intake of vitamin K-rich foods would counteract the effects of warfarin. Avoiding foods high in protein or increasing the intake of foods high in calcium are not specifically related to the use of warfarin.

5. The client is on digoxin and has severe digoxin toxicity. What is the nursing priority action?

• A. Check the potassium level.
• B. Give Digibind as an antidote.
• C. Change the dosing of digoxin to every other day.
• D. Administer a potassium supplement to decrease digoxin toxicity.

Correct answer: B

Rationale: The correct answer is to give Digibind as an antidote in cases of severe digoxin toxicity. Digibind works by binding to digoxin and preventing it from causing further harm. Checking the potassium level (choice A) is important but not the priority when the client has severe toxicity. Changing the dosing to every other day (choice C) is not appropriate in the setting of severe toxicity where immediate action is required. Giving a potassium supplement (choice D) may be needed eventually, but the priority is to administer Digibind to counteract the toxic effects of digoxin.

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