Nursing Elites

1. A client has made an appointment for her annual Papanicolaou test (a.k.a. Pap smear). The nurse who schedules the appointment should tell the client that:

• A. The test cannot be performed while the client is menstruating
• B. Vaginal douching is required at least 24 hours before the test
• C. Spicy foods should not be eaten on the day of the test
• D. The test has absolutely no discomfort associated with it

Correct answer: A

Rationale: The correct answer is A. A Pap smear cannot be performed with accurate results during menstruation. Menstrual blood may interfere with the test results. Choice B is incorrect as vaginal douching should be avoided for at least 24 hours before the test to prevent altering the cervical cells. Choice C is incorrect as there is no restriction on spicy foods before a Pap smear. Choice D is incorrect as some women may experience mild discomfort during the test, although it is generally well-tolerated.

2. 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.

3. Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first?

• A. Elevate extremities on pillows
• B. Evaluate edema for pitting
• C. Assess pulses with a vascular Doppler
• D. Wrap the feet with warmed blankets

Correct answer: C

Rationale: In this scenario, the priority action for the nurse is to assess pulses with a vascular Doppler. The absence of palpable pedal pulses following an abdominal aortic aneurysm repair raises concerns about compromised blood flow, which could lead to serious complications like ischemia or thrombosis. Evaluating and confirming the presence or absence of pulses is crucial to guide further interventions. Elevating extremities on pillows (Choice A) may be beneficial for managing edema, but it is not the immediate priority when pulses are not palpable. Evaluating edema for pitting (Choice B) can provide additional information about fluid status but does not address the primary concern of absent pulses. Wrapping the feet with warmed blankets (Choice D) is not appropriate in this situation and may not address the underlying vascular issue.

4. The client is planning care for a client who is receiving hemodialysis. Which of the following interventions should be included in the plan of care?

• A. Administer anticoagulants to prevent clot formation.
• B. Monitor the client for signs of infection.
• C. Provide the client with a high-protein diet.
• D. Encourage the client to drink at least 2 liters of fluid daily.

Correct answer: B

Rationale: Monitoring for signs of infection is crucial in clients receiving hemodialysis because they are at an increased risk of infection due to the invasive nature of the procedure. Administering anticoagulants is not typically a part of the routine care for clients undergoing hemodialysis unless specifically prescribed. While a high-protein diet may be beneficial for some clients, it is not a specific intervention related to hemodialysis. Encouraging fluid intake must be individualized based on the client's fluid status and should not be a generalized recommendation for all clients receiving hemodialysis.

5. The nurse instructs the unlicensed nursing personnel (UAP) on how to provide oral hygiene for clients who cannot perform this task for themselves. Which of the following techniques should the nurse tell the UAP to incorporate into the client's daily care?

• A. Assess the oral cavity each time mouth care is given and record observations.
• B. Use a soft toothbrush to brush the client's teeth after each meal.
• C. Swab the client's tongue, gums, and lips with a soft foam applicator every 2 hours.
• D. Rinse the client's mouth with mouthwash several times a day.

Correct answer: B

Rationale: The correct technique to incorporate into the client's daily care for oral hygiene is to use a soft toothbrush to brush the client's teeth after each meal. This helps in maintaining oral hygiene for clients who cannot perform this task themselves. Choice A is incorrect because assessing the oral cavity each time mouth care is given is important but not the technique to incorporate into daily care. Choice C is incorrect as swabbing the tongue, gums, and lips every 2 hours may not be necessary for daily care. Choice D is incorrect as rinsing the client's mouth with mouthwash several times a day may not be suitable for all clients and is not a standard recommendation for daily oral care.

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