Nursing Elites

1. A client is receiving Cilostazol (Pletal) for peripheral arterial disease causing intermittent claudication. The nurse determines this medication is effective when the client reports which of the following?

• A. I am having fewer aches and pains.
• B. I do not have headaches anymore.
• C. I am able to walk further without leg pain.
• D. My toes are turning grayish black in color.

Correct answer: C

Rationale: The correct answer is C. Cilostazol improves blood flow to the muscles, which helps alleviate symptoms of intermittent claudication. An improvement in walking distance without leg pain indicates the effectiveness of the medication. Choices A and B are not directly related to the expected outcome of Cilostazol therapy for intermittent claudication. Choice D is concerning for a potential adverse effect and should be reported to the healthcare provider immediately.

2. A client is tested for HIV with the use of an enzyme-linked immunosorbent assay (ELISA), and the test result is positive. The nurse should tell the client that:

• A. HIV infection has been confirmed
• B. The client probably has an opportunistic infection
• C. The test will need to be confirmed with the use of a Western blot
• D. A positive test is a normal result and does not mean that the client is infected with HIV

Correct answer: C

Rationale: When an ELISA test for HIV is positive, it is essential to confirm the result with a Western blot. The Western blot is the confirmatory test for HIV. Choice A is incorrect because a positive ELISA test does not confirm HIV infection. Choice B is incorrect as it assumes a different diagnosis. Choice D is incorrect because a positive ELISA test does indicate potential HIV infection and requires confirmation.

3. The nurse is preparing to administer the first dose of an antibiotic to a patient admitted for a urinary tract infection. Which action is most important prior to administering the antibiotic?

• A. Administering a small test dose to determine if hypersensitivity exists
• B. Having epinephrine available in case of a severe hypersensitivity reaction
• C. Monitoring baseline vital signs, including temperature and blood pressure
• D. Obtaining a specimen for culture and sensitivity

Correct answer: D

Rationale: The most crucial action before administering an antibiotic for a urinary tract infection is to obtain a specimen for culture and sensitivity. This ensures the accurate identification of the causative organism and helps determine the most effective antibiotic therapy. Administering a test dose to detect hypersensitivity is usually reserved for cases with a strong suspicion of allergy to a needed antibiotic. Keeping epinephrine available is important when there is a significant risk of a severe allergic reaction. Monitoring baseline vital signs is essential during antibiotic therapy but is not the top priority before administering the first dose.

4. 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.

5. After delegating to an unlicensed assistive personnel (UAP) the task of completing a bladder scan examination for a client, the nurse evaluates the UAP’s performance. Which action by the UAP indicates the nurse must provide additional instructions when delegating this task?

• A. Selecting the female icon for all female clients and the male icon for all male clients
• B. Explaining to the client, 'This test measures the amount of urine in your bladder.'
• C. Applying ultrasound gel to the scanning head and cleaning it after use
• D. Taking at least two readings using the aiming icon to position the scanning head

Correct answer: A

Rationale: The correct answer is A because the UAP should select the female icon for women who have not had a hysterectomy to allow the scanner to subtract the volume of the uterus from readings. If a woman has had a hysterectomy, the UAP should choose the male icon. Choice B is incorrect as it is essential for the UAP to explain the procedure to the client to ensure understanding. Choice C is incorrect because applying ultrasound gel to the scanning head and cleaning it after use are appropriate actions. Choice D is incorrect as it is necessary for the UAP to take at least two readings using the aiming icon to position the scanning head accurately for an effective bladder scan examination.

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