Nursing Elites

1. When monitoring a client who is receiving tissue plasminogen activator (t-PA), the nurse should have resuscitation equipment available because reperfusion of the cardiac tissue can result in which of the following?

• A. Cardiac arrhythmias.
• B. Hypertension.
• C. Seizures.
• D. Hypothermia.

Correct answer: A

Rationale: The correct answer is A: Cardiac arrhythmias. Reperfusion of cardiac tissue following t-PA administration can lead to cardiac arrhythmias, necessitating resuscitation equipment. Hypertension (choice B) is a common side effect of t-PA but is not directly related to reperfusion. Seizures (choice C) and hypothermia (choice D) are not typically associated with reperfusion from t-PA administration.

2. A client has undergone renal angiography via the right femoral artery. The nurse determines that the client is experiencing a complication of the procedure upon noting:

• A. Urine output of 40 mL/hr
• B. Blood pressure of 118/76 mm Hg
• C. Respiratory rate of 18 breaths/min
• D. Pallor and coolness of the right leg

Correct answer: D

Rationale: Pallor and coolness of the right leg indicate a potential vascular complication following renal angiography, such as hemorrhage, thrombosis, or embolism. These signs suggest impaired circulation in the affected limb. Urine output, blood pressure, and respiratory rate are not typically associated with complications of renal angiography. Complications of this procedure mainly involve allergic reactions to the dye, dye-induced renal damage, and various vascular issues.

3. The nurse is assessing a client with a diagnosis of pre-renal acute kidney injury (AKI). Which condition would the nurse expect to find in the client’s recent history?

• A. Pyelonephritis
• B. Myocardial infarction
• C. Bladder cancer
• D. Kidney stones

Correct answer: B

Rationale: In pre-renal acute kidney injury, there is a decrease in perfusion to the kidneys. Myocardial infarction can lead to decreased blood flow to the kidneys, causing pre-renal AKI. Pyelonephritis is an intrinsic/intrarenal cause of AKI involving kidney damage. Bladder cancer and kidney stones are post-renal causes of AKI due to urinary flow obstruction, not related to perfusion issues seen in pre-renal AKI.

4. What is the most common cause of peptic ulcers?

• A. Helicobacter pylori infection
• B. NSAID use
• C. Excessive alcohol consumption
• D. Stress

Correct answer: A

Rationale: Helicobacter pylori infection is the most common cause of peptic ulcers. This bacterium can weaken the protective mucous coating of the stomach and duodenum, allowing acid to get through to the sensitive lining beneath. NSAID use (Choice B) can also cause peptic ulcers by disrupting the stomach's mucosal barrier. Excessive alcohol consumption (Choice C) and stress (Choice D) can exacerbate and contribute to ulcer formation but are not the primary cause.

5. During a paracentesis procedure on a client with abdominal ascites, into which position would the nurse assist the client?

• A. Supine
• B. Upright
• C. Left side-lying
• D. Right side-lying

Correct answer: B

Rationale: During a paracentesis procedure for a client with abdominal ascites, the nurse should assist the client into an upright position. Placing the client upright allows the intestines to float posteriorly, reducing the risk of intestinal laceration during catheter insertion. Choices A, C, and D are incorrect because a supine, left side-lying, or right side-lying position would not provide the same benefit of intestinal mobility and protection during the procedure.

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