Nursing Elites

1. A patient is to be administered an immunization. The serum contains aluminum phosphate. What route is most appropriate to administer this immunization?

• A. Intramuscularly
• B. Subcutaneously
• C. Intravenously
• D. Orally

Correct answer: A

Rationale: The most appropriate route to administer an immunization containing aluminum phosphate is intramuscularly. Aluminum phosphate is commonly used as an adjuvant in vaccines to enhance the immune response. Intramuscular administration allows for the vaccine to be delivered into the muscle tissue, where it can be effectively absorbed by the body's immune cells. Subcutaneous administration is not ideal for vaccines containing aluminum phosphate, as it may not elicit the desired immune response. Intravenous administration is typically reserved for specific medications or situations that require rapid absorption into the bloodstream. Oral administration is not suitable for vaccines containing aluminum phosphate as they would be degraded in the gastrointestinal tract.

2. A client with multiple sclerosis (MS) is experiencing a relapse. Which of the following factors is most likely contributing to the relapse?

• A. Taking an over-the-counter multivitamin
• B. Experiencing high levels of emotional stress
• C. Getting a flu shot
• D. Engaging in strenuous physical activity

Correct answer: B

Rationale: Emotional stress can trigger a relapse in multiple sclerosis by exacerbating symptoms. While taking an over-the-counter multivitamin and getting a flu shot are generally safe, they are not typically known to trigger MS relapses. Engaging in strenuous physical activity, if done carefully, can actually have benefits for individuals with MS by improving strength and mobility, so it is less likely to be the cause of a relapse.

3. A patient is prescribed clomiphene citrate (Clomid) for the treatment of infertility. Which of the following statements should be included in the nurse's teaching?

• A. This drug induces ovulation by stimulating gonadotropins.
• B. This drug induces ovulation by inhibiting gonadotropins.
• C. This drug suppresses ovulation by inhibiting gonadotropins.
• D. This drug increases progesterone levels, which maintains pregnancy.

Correct answer: A

Rationale: The correct statement to include in the nurse's teaching is that clomiphene induces ovulation by stimulating the release of gonadotropins, which in turn stimulate the ovaries. Choice B is incorrect because clomiphene does not induce ovulation by inhibiting gonadotropins. Choice C is also incorrect as clomiphene does not suppress ovulation by inhibiting gonadotropins. Choice D is inaccurate as clomiphene does not directly increase progesterone levels to maintain pregnancy.

4. Cellular swelling is:

• A. Irreversible
• B. Evident early in all types of cellular injury
• C. Manifested by decreased intracellular sodium
• D. None of the above is correct

Correct answer: B

Rationale: Cellular swelling is indeed evident early in all types of cellular injury. This occurs due to the influx of water into the cell, leading to swelling. Choice A is incorrect because cellular swelling is reversible if the injury is not severe. Choice C is incorrect because cellular swelling is not manifested by decreased intracellular sodium; in fact, it is associated with increased intracellular sodium due to water influx. Choice D is incorrect as option B is the correct statement.

5. A client has experienced a pontine stroke which has resulted in severe hemiparesis. What priority assessment should the nurse perform prior to allowing the client to eat or drink from the food tray?

• A. Evaluate the client's gag reflex.
• B. Assess the client's bowel sounds.
• C. Check the client's pupil reaction.
• D. Monitor the client's heart rate.

Correct answer: A

Rationale: The correct answer is to evaluate the client's gag reflex. When a client has experienced a stroke resulting in severe hemiparesis, assessing the gag reflex is crucial before allowing them to eat or drink. This assessment helps prevent aspiration, a serious complication that can occur due to impaired swallowing ability. Assessing bowel sounds (Choice B), pupil reaction (Choice C), or heart rate (Choice D) are important assessments but are not the priority in this situation where the risk of aspiration is higher.

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