Nursing Elites

1. Which term refers to the relaxation phase of the heart, during which the chambers fill with blood?

• A. Diastole
• B. Systole
• C. Refractoriness
• D. Automaticity

Correct answer: A

Rationale: The correct answer is A, Diastole. Diastole is the phase of the cardiac cycle when the heart muscles relax, allowing the chambers to fill with blood. Choice B, Systole, is incorrect as systole is the contraction phase of the heart when blood is pumped out of the chambers. Choice C, Refractoriness, refers to a period during which the heart muscle is unresponsive to stimuli. Choice D, Automaticity, relates to the heart's ability to generate its own electrical impulses.

2. The nurse is caring for a client on digoxin. What is the most important assessment before administering this medication?

• A. Check the client’s heart rate.
• B. Check the client’s blood pressure.
• C. Check the client’s respiratory rate.
• D. Check the client’s oxygen saturation.

Correct answer: A

Rationale: The correct answer is to check the client’s heart rate before administering digoxin because one of the side effects of digoxin is bradycardia. Monitoring the heart rate is crucial to assess whether the client's heart rate is within the acceptable range before giving the medication. Checking the blood pressure (Choice B), respiratory rate (Choice C), or oxygen saturation (Choice D) are important assessments in general patient care, but they are not specifically related to the administration of digoxin.

3. What is the term that describes the inability of cardiac cells to respond to a new stimulus while they are still in contraction from a previous stimulus?

• A. Refractoriness
• B. Excitability
• C. Contractility
• D. Automaticity

Correct answer: A

Rationale: Refractoriness is the correct term to describe the inability of cardiac cells to respond to a new stimulus while they are still in contraction from a previous stimulus. This period is essential for the heart to complete its contraction and relaxation phases without interference. Excitability refers to the ability of cells to respond to stimuli, not the inability to respond. Contractility is the force of cardiac muscle contraction, and automaticity is the ability of cardiac cells to generate electrical impulses spontaneously, which are not relevant to the described scenario.

4. 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.

5. The client is on enoxaparin (Lovenox) for DVT prophylaxis. What is the most important lab value to monitor?

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

Correct answer: A

Rationale: The correct answer is A: Platelet count. When a client is on enoxaparin (Lovenox), monitoring the platelet count is crucial as enoxaparin can lead to a rare but serious side effect known as heparin-induced thrombocytopenia (HIT), causing a decrease in platelet count. Monitoring the platelet count helps detect this adverse reaction early. Choices B, C, and D are incorrect because enoxaparin therapy does not directly affect PT/INR, aPTT, or hemoglobin levels.

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