Nursing Elites

1. Prior to administering tissue plasminogen activator (t-PA), the nurse should assess the client for which of the following contraindications to administering the drug?

• A. Age over 60 years.
• B. History of cerebral hemorrhage.
• C. History of heart failure.
• D. Cigarette smoking.

Correct answer: B

Rationale: The correct answer is B: History of cerebral hemorrhage. A history of cerebral hemorrhage is a contraindication to t-PA administration because of the increased risk of bleeding. Choices A, C, and D are incorrect. Age over 60 years is not a contraindication for t-PA administration. While older age may pose some risks, it is not an absolute contraindication. History of heart failure is not a direct contraindication to t-PA administration. Cigarette smoking, while a risk factor for cardiovascular disease, is not a specific contraindication for t-PA administration.

2. When assessing an individual with peripheral vascular disease, which clinical manifestation would indicate complete arterial obstruction in the lower left leg?

• A. Aching pain in the left calf.
• B. Burning pain in the left calf.
• C. Numbness and tingling in the left leg.
• D. Coldness of the left foot and ankle.

Correct answer: D

Rationale: Coldness of the left foot and ankle is the correct clinical manifestation indicating complete arterial obstruction in the lower left leg. Complete arterial obstruction results in reduced blood flow, leading to decreased temperature in the affected area. Aching pain (Choice A) and burning pain (Choice B) are more commonly associated with partial obstructions or ischemia, while numbness and tingling (Choice C) can be indicative of nerve involvement or compromised circulation, but not specifically complete arterial obstruction. The coldness in the foot and ankle is a result of severely reduced blood flow, which impairs the delivery of oxygen and nutrients to the tissues in that area, leading to a lower temperature. This symptom is a critical indicator of a more severe blockage compared to the other options provided.

3. What types of medications should the healthcare provider expect to administer to a client during an acute respiratory distress episode?

• A. Vasodilators and hormones.
• B. Analgesics and sedatives.
• C. Anticoagulants and expectorants.
• D. Bronchodilators and steroids.

Correct answer: D

Rationale: During an acute respiratory distress episode, the priority is to widen air passages, increase air space, and reduce alveolar membrane inflammation. Therefore, the client would likely require bronchodilators to open up the airways and steroids to reduce inflammation. Vasodilators and hormones (Choice A) are not typically indicated in this situation. Analgesics and sedatives (Choice B) may be used for pain management and anxiety but are not primary treatments for respiratory distress. Anticoagulants and expectorants (Choice C) are not the main medications used during an acute respiratory distress episode and may not address the immediate needs of the client.

4. The client is being taught about the best time to plan sexual intercourse in order to conceive. Which information should be provided?

• A. Two weeks before menstruation.
• B. Vaginal mucous discharge is thick.
• C. Low basal temperature.
• D. First thing in the morning.

Correct answer: A

Rationale: The correct answer is A: 'Two weeks before menstruation.' Ovulation typically occurs 14 days before menstruation begins during a typical 28-day cycle. To increase the chances of conception, sexual intercourse should occur within 24 hours of ovulation. High estrogen levels during ovulation lead to changes in vaginal mucous discharge, making it more 'slippery' and stretchy. Basal temperature rises during ovulation. The timing of intercourse during the day is less significant than ensuring it happens around ovulation. The other options are incorrect because planning intercourse two weeks before menstruation is likely to miss the fertile window, thick vaginal mucous discharge indicates ovulation is approaching, and low basal temperature is not indicative of the fertile period.

5. A nurse administers scopolamine as prescribed to a client in preparation for surgery. For which side effect of this medication does the nurse monitor the client?

• A. Pupil constriction
• B. Increased urine output
• C. Complaints of dry mouth
• D. Complaints of feeling sweaty

Correct answer: D

Rationale: The correct answer is D: 'Complaints of feeling sweaty.' Scopolamine, an anticholinergic medication, commonly causes the side effect of decreased sweating, not increased urine output or pupil constriction. While dry mouth is a possible side effect, it is less likely than the altered sweating pattern. Therefore, the nurse should monitor the client for complaints of feeling sweaty due to the potential side effect of decreased sweating associated with scopolamine.

Similar Questions