Nursing Elites

1. A nurse is caring for a patient admitted to the emergency room for an ischemic stroke with marked functional deficits. The physician is considering the use of fibrinolytic therapy with TPA (tissue plasminogen activator). Which history-gathering question would not be important for the nurse to ask?

• A. What time did you first notice symptoms consistently appearing?
• B. Have you been taking any blood thinners such as heparin, lovenox, or warfarin?
• C. Have you had another stroke or head trauma in the previous 3 months?
• D. Have you had any blood transfusions within the previous year?

Correct answer: D

Rationale: The correct answer is 'Have you had any blood transfusions within the previous year?' This question is not relevant in the context of considering fibrinolytic therapy with TPA for an ischemic stroke. Blood transfusions within the previous year do not directly impact the decision to use TPA in the treatment of an acute ischemic stroke. The focus should be on factors such as the time of symptom onset, current medications like blood thinners, and recent history of strokes or head trauma, as these are more directly related to the decision-making process for administering TPA in this emergency situation.

2. A patient is found unconscious in their room with rhythmic jerking of all four extremities and heavy foaming at the mouth. The patient was on seizure precautions with bedrails up and padded. What is the priority action for the nurse to take?

• A. Administer Lorazepam (Ativan)
• B. Turn the patient to his/her side
• C. Call the physician
• D. Suction the patient

Correct answer: B

Rationale: The nurse's priority action should be to turn the patient to his/her side. This position helps maintain an open airway and prevents aspiration of secretions or vomitus. Administering Lorazepam (Ativan) without ensuring a clear airway could lead to further complications. Calling the physician is important, but immediate interventions to protect the airway take precedence. Suctioning the patient may be necessary but should not be the initial action; positioning for airway protection is the priority.

3. Mr. L was working in his garage at home and had an accident with a power saw. He is brought into the emergency department by a neighbor with a traumatic hand amputation. What is the first action of the nurse?

• A. Place a tourniquet at the level of the elbow
• B. Apply direct pressure to the injury
• C. Administer a bolus of 0.9% Normal Saline
• D. Elevate the injured extremity on a pillow

Correct answer: B

Rationale: The correct first action for the nurse in this scenario is to apply direct pressure to the injury. When a client presents with traumatic hand amputation causing excessive bleeding, the immediate goal is to control the bleeding. Applying direct pressure with a sterile dressing helps to stem the flow of blood and stabilize the patient. Placing a tourniquet at the level of the elbow should be avoided initially as it may lead to further complications such as tissue damage. Administering a bolus of 0.9% Normal Saline is not the priority in this situation where hemorrhage control is crucial. Elevating the injured extremity on a pillow does not address the primary concern of controlling the bleeding and stabilizing the patient.

4. The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient?

• A. Supine with the head of the bed elevated 30 degrees
• B. In a high-Fowler's position with the left arm extended
• C. On the right side with the left arm extended above the head
• D. Sitting upright with the arms supported on an overbed table

Correct answer: D

Rationale: The correct position for a patient with a left-sided pleural effusion undergoing thoracentesis is sitting upright with the arms supported on an overbed table. This position helps increase lung expansion, allows fluid to collect at the lung bases, and expands the intercostal space making access to the pleural space easier. Placing the patient supine, in a high-Fowler's position, or on the right side with the left arm extended above the head could increase the work of breathing for the patient and complicate the thoracentesis procedure for the healthcare provider.

5. When obtaining a health history and physical assessment for a 36-year-old female patient with possible multiple sclerosis (MS), the nurse should

• A. assess for the presence of chest pain.
• B. inquire about urinary tract problems.
• C. inspect the skin for rashes or discoloration.
• D. ask the patient about any increase in libido.

Correct answer: B

Rationale: When assessing a patient for possible multiple sclerosis (MS), it is important to inquire about urinary tract problems as they are common symptoms of the condition, such as incontinence or retention. Chest pain is not typically associated with MS, so assessing for its presence is not a priority. Inspecting the skin for rashes or discoloration is not a typical manifestation of MS. Additionally, a decrease in libido, rather than an increase, is more commonly seen in patients with MS. Therefore, the most appropriate action for the nurse in this scenario is to inquire about urinary tract problems.

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