Nursing Elites

1. A client is admitted to the emergency department with symptoms of arm numbness, chest pain, and nausea/vomiting. The examining healthcare provider believes that the client has experienced an acute myocardial infarction (AMI) within the past three hours and would like to initiate tissue plasminogen activator (tPA) therapy. Which client history findings contraindicate the use of tPA?

• A. Treats hypoglycemia with an oral hypoglycemic agent.
• B. Had a cerebrovascular hemorrhage 2 months ago.
• C. Current age 65, father died of MI at 55.
• D. Report of being intolerant of medication that contains aspirin.

Correct answer: B

Rationale: A history of cerebrovascular hemorrhage is a contraindication for tPA therapy due to the risk of bleeding. Choice A is incorrect because treating hypoglycemia with an oral hypoglycemic agent is not a contraindication for tPA therapy. Choice C is incorrect as age and family history of MI do not contraindicate the use of tPA. Choice D is incorrect as being intolerant of medication containing aspirin is not a contraindication for tPA therapy.

2. An older client is receiving an IV of 5% dextrose in 0.45% normal saline at 75 mL/hour. Which assessment finding indicates to the nurse that the client is developing a complication from this therapy?

• A. Capillary refill takes > 3 seconds.
• B. Episodes of vertigo and loss of balance.
• C. Average daily output of 1200 ml.
• D. Pulse rate of 110 beats/minute and dyspnea upon exertion.

Correct answer: D

Rationale: The correct answer is D. Tachycardia and dyspnea are signs of fluid overload, which is a potential complication of IV fluid therapy. Choices A, B, and C are not directly related to fluid overload and are not typical signs of complications associated with the IV fluid therapy being administered.

3. A client who experienced partial-thickness burns with over 50% body surface area (BSA) 2 weeks ago suddenly becomes restless and agitated.

• A. Increase the room temperature.
• B. Assess the oxygen saturation.
• C. Continue to monitor vital signs.
• D. Notify the rapid response team.

Correct answer: D

Rationale: In a burn patient with sudden restlessness and agitation, it is crucial to consider hypoxia or other critical conditions. As such, notifying the rapid response team is the most appropriate action to ensure prompt assessment and intervention. Increasing room temperature (Choice A) is not the priority in this scenario. While monitoring vital signs (Choice C) is important, the sudden change in behavior warrants immediate action. Assessing oxygen saturation (Choice B) is a step in the right direction, but involving the rapid response team ensures a comprehensive evaluation and timely management of the patient's condition.

4. The nurse is caring for a newborn with a myelomeningocele. Before surgery, what should the nursing interventions include?

• A. Leaving the lesion uncovered and placing the infant supine
• B. Covering the lesion with a sterile, saline-soaked gauze
• C. Applying lotion to the lesion to keep it moist
• D. Covering the lesion with a dry, sterile gauze

Correct answer: B

Rationale: The correct intervention before surgery for a newborn with a myelomeningocele is to cover the lesion with a sterile, saline-soaked gauze. This helps protect the exposed spinal cord and meninges from infection and damage. Choice A is incorrect because leaving the lesion uncovered can increase the risk of infection. Choice C is incorrect because applying lotion can introduce contaminants to the lesion. Choice D is incorrect because covering the lesion with a dry gauze can lead to adherence of the gauze to the wound, causing trauma upon removal and disrupting the healing process.

5. An older female client has normal saline infusing at 45 ml/hour. She complains of pain at the insertion of the IV catheter. There is no redness or edema around the IV site. Which action should the nurse take?

• A. Determine what IV medications have recently been administered.
• B. Slow the infusion rate.
• C. Apply a warm compress to the IV site.
• D. Discontinue the IV line and start a new one.

Correct answer: A

Rationale: The correct action for the nurse to take in this scenario is to determine what IV medications have recently been administered. This is important to identify if the pain at the IV site is related to a medication infusion. Slowing the infusion rate (choice B) may not address the underlying cause of the pain. Applying a warm compress (choice C) is not necessary since there is no redness or edema around the IV site. Discontinuing the IV line and starting a new one (choice D) is a drastic step and should not be the first action taken without investigating the cause of the pain.

Similar Questions