Nursing Elites

1. A client is to receive thrombolytic therapy. Which of the following factors should be recognized as a contraindication to the therapy?

• A. Hip arthroplasty 2 weeks ago
• B. Elevated sedimentation rate
• C. Incident of exercise-induced asthma 1 week ago
• D. Elevated platelet count

Correct answer: A

Rationale: Thrombolytic therapy involves the use of medications to dissolve blood clots. Hip arthroplasty (joint replacement surgery) performed recently is a contraindication to thrombolytic therapy due to the risk of bleeding. Elevated sedimentation rate, exercise-induced asthma, and elevated platelet count are not contraindications to thrombolytic therapy.

2. What is the term for the body's ability to defend itself against specific invading agents such as bacteria, toxins, viruses, and foreign bodies?

• A. Hormones
• B. Secretion
• C. Immunity
• D. Glands

Correct answer: C

Rationale: The correct answer is C: Immunity. Immunity refers to the body's ability to protect itself against specific invading agents like bacteria, toxins, viruses, and foreign bodies by recognizing and destroying them. It is a crucial defense mechanism that helps maintain health and prevent infections and diseases. Choices A, B, and D are incorrect because hormones are chemical messengers, secretion is the process of releasing substances, and glands are organs that produce and release substances, none of which specifically relate to the body's defense against invading agents.

3. What is required for effective hand washing?

• A. Soap or detergent to promote emulsification
• B. Hot water to destroy bacteria
• C. A disinfectant to increase surface tension
• D. All of the above

Correct answer: A

Rationale: To effectively wash hands, soap or detergent is essential as they help emulsify fats and oils, allowing them to be rinsed away. Hot water alone cannot effectively destroy bacteria, and a disinfectant is not typically required for routine hand washing.

4. The healthcare provider orders the administration of an ampicillin capsule TID p.o. The healthcare provider should give the medication...

• A. Three times a day orally
• B. Three times a day after meals
• C. Two times a day by mouth
• D. Two times a day before meals

Correct answer: A

Rationale: In medical abbreviations, 'TID' stands for 'ter in die,' which means three times a day, and 'p.o.' stands for 'per os,' which means orally. Therefore, the correct administration schedule for the ampicillin capsule is three times a day orally. Choices B, C, and D are incorrect because they do not align with the prescribed frequency or route of administration specified in the order.

5. A patient presents with an exacerbation of chronic obstructive pulmonary disease (COPD) characterized by shortness of breath, orthopnea, thick, tenacious secretions, and a dry hacking cough. An appropriate nursing diagnosis would be:

• A. Ineffective airway clearance related to thick, tenacious secretions.
• B. Ineffective airway clearance related to dry, hacking cough.
• C. Ineffective individual coping with COPD.
• D. Pain related to immobilization of affected leg.

Correct answer: A

Rationale: The patient's symptoms of shortness of breath, orthopnea, thick, tenacious secretions, and a dry hacking cough all point towards a potential airway clearance issue. This makes option A, 'Ineffective airway clearance related to thick, tenacious secretions,' the most appropriate nursing diagnosis. It directly addresses the thick secretions and suggests a potential cause of the breathing difficulty the patient is experiencing.

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