Question

A nurse in an emergency department (ED) is caring for a female client.

Answer 1

Correct Answers

Administer hydralazine IV. [ inappropriate ]
Administer sodium polystyrene rectally. [ appropriate ]
Administer insulin IV. [ appropriate ]
Administer calcium gluconate IV. [ appropriate ]
Administer potassium chloride IV. [ inappropriate ]

Rationale :

Appropriate

Administer sodium polystyrene rectally

🔶Sodium polystyrene sulfonate lowers serum potassium by exchanging sodium for potassium within the gastrointestinal tract.

🔶The bound potassium is then removed from the body through stool, producing an actual reduction in total-body potassium.

🔶Rectal administration can be used when oral administration is not appropriate or when the client cannot safely take the medication by mouth.

🔶Its effect is relatively slow, so it should not be relied upon as the only treatment when hyperkalemia has already produced ECG abnormalities.

🔶It is appropriate as an adjunct to faster therapies while the nurse monitors bowel function, potassium levels, and signs of intestinal complications.

Administer insulin IV

🔶 Intravenous regular insulin rapidly shifts potassium from the extracellular fluid into the body’s cells.

🔶Insulin stimulates the sodium-potassium pump, lowering the serum potassium concentration without immediately removing potassium from the body.

🔶This intervention is appropriate because the client has both an elevated potassium level and dangerous ECG manifestations.

🔶IV dextrose is commonly administered with insulin unless the client is significantly hyperglycemic, because insulin can cause severe hypoglycemia.

🔶The nurse should monitor blood glucose frequently and reassess the potassium level and cardiac rhythm after treatment.

Administer calcium gluconate IV

🔶Intravenous calcium gluconate stabilizes the cardiac cell membrane and reduces the risk of ventricular dysrhythmias caused by hyperkalemia.

🔶It is especially indicated when ECG changes such as peaked T waves, absent P waves, bradycardia, or QRS widening are present.

🔶Calcium gluconate acts rapidly but does not lower the serum potassium concentration or remove potassium from the body.

🔶Potassium-lowering treatments such as insulin with dextrose must therefore be administered in addition to calcium.

🔶The nurse should maintain continuous ECG monitoring and administer the medication slowly through a patent IV line according to the prescribed rate.

Inappropriate

Administer hydralazine IV

🔶 Hydralazine is an antihypertensive vasodilator that lowers blood pressure and does not treat hyperkalemia or its cardiac effects.

🔶The client’s blood pressure is already low-normal at 98/64 mm Hg, so hydralazine could cause dangerous hypotension.

Administer potassium chloride IV

🔶Potassium chloride would further increase the client’s already elevated serum potassium and worsen the risk of lethal cardiac dysrhythmias.

🔶Potassium-containing medications and fluids should be withheld while emergency measures are used to stabilize the heart and reduce potassium.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Morphine
Aspirin
Heparin

Rationale :

Morphine

💊 Morphine may be prescribed for severe, persistent ischemic chest pain that is not relieved by first-line treatment such as nitroglycerin.

💊 It reduces pain and anxiety while producing venodilation, which can decrease venous return and myocardial oxygen demand.

💊 The medication should be administered cautiously because it can cause hypotension, respiratory depression, sedation, and bradycardia.

💊 The nurse should monitor blood pressure, respiratory status, level of consciousness, and pain response closely after administration.

💊 Morphine is not routinely given to every STEMI client, but it is appropriate when significant chest pain continues despite initial anti-ischemic therapy.

Aspirin

🩸 Aspirin should be administered promptly to a client with a suspected acute myocardial infarction unless a contraindication exists.

🩸 It irreversibly inhibits platelet aggregation and helps prevent the coronary thrombus from enlarging.

🩸 The client is usually instructed to chew non-enteric-coated aspirin because chewing promotes faster absorption and a more rapid antiplatelet effect.

🩸 Early aspirin administration reduces recurrent myocardial infarction, vascular complications, and mortality.

🩸 The nurse should assess for active bleeding, severe aspirin allergy, and other contraindications before administering it.

Heparin

🛡️ Heparin is an anticoagulant used during acute coronary syndrome to prevent further formation and extension of the coronary thrombus.

🛡️ It does not dissolve the existing clot but inhibits clotting factors and reduces the risk of additional coronary artery occlusion.

🛡️ Heparin is commonly administered when the client is being prepared for percutaneous coronary intervention or receiving other reperfusion therapy.

🛡️ The nurse should monitor for bleeding, thrombocytopenia, hematuria, gastrointestinal bleeding, and changes in prescribed coagulation studies.

🛡️ Its use supports coronary reperfusion treatment and helps reduce recurrent ischemic events during the acute phase of STEMI care.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Highlights :

Client is currently taking lisinopril 5 mg PO daily.
Sodium 130 mEq/L (136 to 145 mEq/L)
Potassium 5.6 mEq/L (3.5 to 5 mEq/L)
BUN 30 mg/dL (10 to 20 mg/dL)
Creatine 3 mg/dL (0.5 to 1 mg/dL)

Rationale :

The client is currently taking lisinopril 5 mg PO daily

🩺 Lisinopril is an ACE inhibitor that reduces aldosterone secretion and can increase the serum potassium level.

🩺 Spironolactone is a potassium-sparing diuretic that also blocks aldosterone and promotes potassium retention.

🩺 Administering these medications together significantly increases the client’s risk for severe hyperkalemia.

🩺 This interaction is especially dangerous because the client already has elevated potassium and impaired renal function.

🩺 The nurse should report the concurrent lisinopril therapy before administering the newly prescribed spironolactone.

Sodium 130 mEq/L

🩺 A sodium level of 130 mEq/L indicates hyponatremia, which can be worsened by diuretic therapy.

🩺 Spironolactone promotes sodium and water excretion while retaining potassium.

🩺 Further sodium loss can increase the risk for weakness, confusion, headache, seizures, and other neurological complications.

🩺 The sodium imbalance should be evaluated before spironolactone is initiated, particularly in a client with renal impairment.

🩺 The nurse should report this abnormal laboratory result so the provider can determine whether the medication is safe.

Potassium 5.6 mEq/L

🩺 A potassium level of 5.6 mEq/L indicates hyperkalemia, which is a major contraindication to spironolactone therapy.

🩺 Spironolactone blocks aldosterone and decreases renal potassium excretion, causing additional potassium retention.

🩺 Further elevation can produce muscle weakness, paresthesia, conduction abnormalities, life-threatening dysrhythmias, and cardiac arrest.

🩺 The risk is increased because the client is also taking lisinopril, which can elevate potassium.

🩺 The nurse should withhold the medication and immediately report the elevated potassium level to the provider.

BUN 30 mg/dL

🩺 A BUN level of 30 mg/dL is elevated and suggests decreased renal clearance, dehydration, or another form of renal dysfunction.

🩺 Spironolactone depends on adequate kidney function for safe elimination and electrolyte regulation.

🩺 Impaired renal function increases the risk that potassium will accumulate to dangerous levels.

🩺 The elevated BUN is especially concerning when considered with the client’s markedly elevated creatinine level.

🩺 The nurse should report this result before administering spironolactone so renal function can be further evaluated.

Creatinine 3 mg/dL

🩺 A creatinine level of 3 mg/dL indicates significant renal impairment.

🩺 Clients with severely reduced kidney function cannot excrete potassium effectively, increasing the risk for spironolactone-induced hyperkalemia.

🩺 Spironolactone is generally avoided or used with extreme caution in clients with substantial renal dysfunction.

🩺 The combination of renal impairment, existing hyperkalemia, and concurrent lisinopril therapy creates a high risk for a life-threatening electrolyte disturbance.

🩺 The nurse should report the elevated creatinine and clarify the prescription before administering the medication.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

"Rotate Injection sites."
"Inject the medication at a 90-degree angle."
"Pinch up a skin area before Injection."

Rationale :

“Rotate injection sites.”

💉 Rotating injection sites helps prevent repeated trauma to the same area of subcutaneous tissue.

💉 Enoxaparin is commonly administered into the left or right anterolateral or posterolateral abdominal wall, at least 5 cm or 2 inches from the umbilicus.

💉 The client should alternate sides and avoid injecting into bruised, scarred, tender, hardened, or inflamed areas.

💉 Site rotation decreases the risk of bruising, hematoma formation, tissue irritation, and poor medication absorption.

💉 The nurse should instruct the client to keep a simple record of injection locations to ensure consistent rotation.

“Inject the medication at a 90-degree angle.”

💉 Enoxaparin is administered into the subcutaneous tissue, and a 90-degree angle is appropriate when a skinfold is pinched.

💉 The needle should be inserted completely into the skinfold to ensure that the medication reaches fatty tissue rather than muscle.

💉 Injecting the medication into muscle can increase the risk of bleeding and hematoma formation because enoxaparin is an anticoagulant.

💉 The medication should be injected slowly and steadily while the client continues holding the skinfold.

💉 After the medication is delivered, the needle should be withdrawn at the same angle and disposed of immediately in a sharps container.

“Pinch up a skin area before injection.”

💉 Pinching a fold of skin separates the subcutaneous fatty tissue from the underlying muscle.

💉 This technique helps ensure that enoxaparin is deposited in the correct tissue layer and reduces the chance of intramuscular administration.

💉 The client should gently grasp the abdominal skin between the thumb and fingers without squeezing excessively.

💉 The skinfold should remain pinched throughout the injection and should be released only after the needle has been removed.

💉 Correct skinfold technique promotes reliable medication absorption and reduces the risk of bleeding, pain, and tissue injury.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

Epigastric pain

Rationale :

💊 Gemfibrozil lowers triglycerides but can increase cholesterol secretion into bile, raising the risk of gallstone formation.

💊 Persistent or severe epigastric or right upper-quadrant pain can indicate cholelithiasis or inflammation of the gallbladder.

💊 The pain may occur with nausea, vomiting, fever, jaundice, or tenderness after eating fatty foods.

💊 The client should promptly report this symptom because gallbladder complications may require laboratory testing, imaging, and discontinuation of the medication.

💊 The nurse should also teach the client to report unexplained muscle pain because gemfibrozil can rarely cause myopathy or rhabdomyolysis.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Tinnitus

Rationale :

👂 Tinnitus, or ringing in the ears, is a classic early manifestation of salicylism from excessive aspirin exposure.

👂 Other early findings can include headache, dizziness, sweating, nausea, vomiting, and decreased hearing.

👂 More severe toxicity can cause tachypnea, fever, confusion, metabolic abnormalities, seizures, and coma.

👂 The nurse should hold further aspirin doses and notify the provider when salicylate toxicity is suspected.

👂 Serum salicylate levels, acid-base balance, electrolytes, respiratory status, and neurological status should be evaluated promptly.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

Seizure

Rationale :

⚠️ A seizure is a severe neurological manifestation of lithium toxicity and requires immediate intervention.

⚠️ Severe toxicity can progress to confusion, coarse tremors, ataxia, coma, cardiovascular instability, and permanent neurological injury.

⚠️ The nurse should withhold lithium, protect the client from injury, maintain the airway, and notify the provider immediately.

⚠️ An urgent serum lithium level, electrolyte panel, renal function tests, and continuous neurological monitoring are indicated.

⚠️ Severe toxicity may require aggressive IV hydration or hemodialysis, particularly when renal clearance is impaired.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Phenelzine

Rationale :

🚨 Phenelzine is a nonselective monoamine oxidase inhibitor that can interact dangerously with levodopa.

🚨 Combining these medications can produce excessive catecholamine activity and trigger a life-threatening hypertensive crisis.

🚨 Manifestations may include severe headache, markedly elevated blood pressure, chest pain, palpitations, diaphoresis, and neurological changes.

🚨 Phenelzine generally must be discontinued for at least 14 days before levodopa therapy is initiated.

🚨 The nurse should complete a thorough medication reconciliation and immediately clarify concurrent prescriptions for these medications.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

Fluid retention

Rationale :

💧 Pioglitazone can cause sodium and water retention, resulting in peripheral edema and weight gain.

💧 Fluid retention can precipitate or worsen heart failure, especially in clients with existing cardiac dysfunction.

💧 The nurse should monitor daily weight, peripheral edema, lung sounds, shortness of breath, and activity tolerance.

💧 Rapid weight gain, orthopnea, crackles, or increasing dyspnea should be reported promptly to the provider.

💧 Pioglitazone is generally avoided in clients with severe or uncontrolled heart failure because of this adverse effect.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

WBC count 2.5 / mm³ (5,000 to 10,000 / mm³)

Rationale :

🩸 A WBC count of 2.5/mm³ is critically low and suggests severe leukopenia associated with clozapine-induced neutropenia or agranulocytosis.

🩸 Clozapine can suppress bone marrow production of neutrophils, leaving the client vulnerable to rapidly developing and potentially fatal infections.

🩸 The medication should be withheld, and the provider should be notified immediately according to the clozapine monitoring protocol.

🩸 The nurse should assess for fever, sore throat, chills, mouth ulcers, malaise, and other signs of infection.

🩸 An absolute neutrophil count should be obtained because it is the primary laboratory value used to determine whether clozapine can be safely continued.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Provider Prescription	appropriate	inappropriate
Administer hydralazine IV.
Administer sodium polystyrene rectally.
Administer insulin IV.
Administer calcium gluconate IV.
Administer potassium chloride IV.

QLexNursing

1 :
A nurse in an emergency department (ED) is caring for a female client.

Correct Answers

2 :
A nurse is caring for a client in an emergency department (ED).

Answer Options

3 :
A nurse is assessing a female client.

Correct Highlights :

4 :
A nurse is caring for a client.

Answer Options

5 :
A nurse is teaching a client who has a new prescription for gemfibrozil. Which of the following findings should the nurse instruct the client to report as an adverse effect of the medication?

6 :
A nurse is assessing a client who takes prescribed daily aspirin. Which of the following findings indicates salicylism?

7 :
A nurse is reviewing the medical record of a client who has been taking lithium. Which of the following findings should the nurse notify the provider of immediately?

8 :
A nurse is caring for a client who has Parkinson's disease and a new prescription for levodopa. The nurse should identify which of the following medications can interact with levodopa to cause a life-threatening complication?

9 :
A nurse is caring for a client who has diabetes mellitus and is taking pioglitazone. The nurse should monitor the client for which of the following adverse effects?

10 :
A nurse is reviewing the medical record of a client who is taking clozapine. Which of the following findings should the nurse report to the provider immediately?

QLexNursing

1 : A nurse in an emergency department (ED) is caring for a female client.

Correct Answers

2 : A nurse is caring for a client in an emergency department (ED).

Answer Options

3 : A nurse is assessing a female client.

Correct Highlights :

4 : A nurse is caring for a client.

Answer Options

5 : A nurse is teaching a client who has a new prescription for gemfibrozil. Which of the following findings should the nurse instruct the client to report as an adverse effect of the medication?

6 : A nurse is assessing a client who takes prescribed daily aspirin. Which of the following findings indicates salicylism?

7 : A nurse is reviewing the medical record of a client who has been taking lithium. Which of the following findings should the nurse notify the provider of immediately?

8 : A nurse is caring for a client who has Parkinson's disease and a new prescription for levodopa. The nurse should identify which of the following medications can interact with levodopa to cause a life-threatening complication?

9 : A nurse is caring for a client who has diabetes mellitus and is taking pioglitazone. The nurse should monitor the client for which of the following adverse effects?

10 : A nurse is reviewing the medical record of a client who is taking clozapine. Which of the following findings should the nurse report to the provider immediately?

1 :
A nurse in an emergency department (ED) is caring for a female client.

2 :
A nurse is caring for a client in an emergency department (ED).

3 :
A nurse is assessing a female client.

4 :
A nurse is caring for a client.

5 :
A nurse is teaching a client who has a new prescription for gemfibrozil. Which of the following findings should the nurse instruct the client to report as an adverse effect of the medication?

6 :
A nurse is assessing a client who takes prescribed daily aspirin. Which of the following findings indicates salicylism?

7 :
A nurse is reviewing the medical record of a client who has been taking lithium. Which of the following findings should the nurse notify the provider of immediately?

8 :
A nurse is caring for a client who has Parkinson's disease and a new prescription for levodopa. The nurse should identify which of the following medications can interact with levodopa to cause a life-threatening complication?

9 :
A nurse is caring for a client who has diabetes mellitus and is taking pioglitazone. The nurse should monitor the client for which of the following adverse effects?

10 :
A nurse is reviewing the medical record of a client who is taking clozapine. Which of the following findings should the nurse report to the provider immediately?