Nursing Elites

1. A client with heart failure is receiving instructions about laxative use. The client should be advised to avoid which of the following laxatives?

• A. Sodium phosphate
• B. Psyllium
• C. Bisacodyl
• D. Polyethylene glycol

Correct answer: A

Rationale: Clients with heart failure often have sodium restrictions. Sodium phosphate can lead to fluid retention due to sodium absorption, which is harmful for individuals with heart failure. Therefore, it should be avoided in this population to prevent exacerbating fluid overload. Psyllium, Bisacodyl, and Polyethylene glycol are safer options for individuals with heart failure as they do not pose the risk of exacerbating fluid overload through sodium retention.

2. Why should the nitrate patch be off for 8 hours per day?

• A. “There is no reason to take the patch off each day.”
• B. “The patch can be addictive; leaving it off reduces the addiction.”
• C. “You should only leave the patch off for 15 minutes.”
• D. “Leaving the patch off for 8 hours per day helps to delay the development of tolerance.”

Correct answer: D

Rationale: Removing the nitrate patch for 8 hours each day is essential to prevent the body from developing tolerance to the medication. By allowing the body to have a drug-free period, the effectiveness of the medication is maintained over time. This practice helps in ensuring that the nitrate patch continues to provide its intended therapeutic effects without diminishing its efficacy. Therefore, it is important for the client to adhere to the prescribed schedule of removing the patch for 8 hours daily to optimize the treatment outcomes.

3. A healthcare professional is preparing to initiate IV therapy for an older adult client. Which of the following actions should the professional plan to take?

• A. Use an electric shaver to remove excess hair on the extremity.
• B. Select the antecubital area to insert the IV catheter.
• C. Distend the veins by using a blood pressure cuff.
• D. Instruct the client to keep the extremity still during the procedure.

Correct answer: C

Rationale: Distending the veins using a blood pressure cuff is essential for facilitating visualization and access to the veins during IV catheter insertion. This technique helps healthcare professionals identify suitable veins, reducing the risk of complications like infiltration or hematoma formation. Using an electric shaver to remove hair on the extremity (Choice A) may increase the risk of micro-cuts and introduce infection. Selecting the antecubital area (Choice B) may not always be appropriate, as vein condition and accessibility vary among older adult clients. Instructing the client to keep the extremity still (Choice D) is important but is not directly related to preparing for IV therapy.

4. What is the antidote for Heparin?

• A. Protamine sulfate
• B. Narcan
• C. Romazicon
• D. Naloxone

Correct answer: A

Rationale: The correct answer is A: Protamine sulfate. Heparin is an anticoagulant medication used to prevent blood clots. In cases of overdose or excessive bleeding due to Heparin, protamine sulfate is administered as the specific antidote. Protamine sulfate works by neutralizing Heparin's anticoagulant activity. Choices B, C, and D are incorrect. Narcan (Naloxone) is used to reverse opioid overdose, Romazicon (Flumazenil) is used to reverse benzodiazepine overdose, and Naloxone is also used to reverse opioid overdose but is not the antidote for Heparin.

5. A healthcare professional is planning to administer IV Alteplase to a client who is demonstrating manifestations of a massive Pulmonary Embolism. Which of the following interventions should the healthcare professional plan to take?

• A. Administer IM Enoxaparin along with the Alteplase dose.
• B. Hold direct pressure on puncture sites for up to 30 min.
• C. Administer Aminocaproic acid IV prior to alteplase infusion.
• D. Prepare to administer Alteplase within 8 hr of manifestation onset.

Correct answer: B

Rationale: The correct intervention when administering IV Alteplase is to hold direct pressure on puncture sites for 10 to 30 minutes or until oozing of blood stops. This helps prevent bleeding complications associated with thrombolytic therapy. Administering IM Enoxaparin is not indicated with Alteplase, as it is an anticoagulant rather than a thrombolytic agent. Aminocaproic acid is not typically administered prior to alteplase infusion in the context of a massive Pulmonary Embolism. While timely administration of Alteplase is important, the specific timeframe within which it should be administered may vary based on the clinical situation, so a strict 8-hour window is not universally applicable.

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