Nursing Elites

1. A client who is taking ciprofloxacin (Cipro) reports to the nurse of having a loss of appetite and a metallic taste in the mouth. What action should the nurse implement?

• A. Reassure the client that these are common side effects of ciprofloxacin.
• B. Instruct the client to take ciprofloxacin with food.
• C. Notify the healthcare provider of the client's symptoms.
• D. Encourage the client to increase fluid intake.

Correct answer: C

Rationale: The correct action for the nurse to take when a client on ciprofloxacin reports loss of appetite and a metallic taste in the mouth is to notify the healthcare provider of the client's symptoms. These symptoms could indicate a need for a change in medication or additional treatment, which the healthcare provider would need to assess. Instructing the client to take ciprofloxacin with food (choice B) may help with gastrointestinal upset but will not address the reported symptoms. Reassuring the client (choice A) is important for providing emotional support but does not address the need for further evaluation. Encouraging increased fluid intake (choice D) is generally beneficial but may not directly address the specific side effects reported.

2. The nurse is caring for a client who is receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. Which action is most important for the nurse to implement?

• A. Monitor the client's respiratory status
• B. Teach the client how to use the PCA pump
• C. Evaluate the client's pain level
• D. Assess the client's pain level

Correct answer: A

Rationale: The correct answer is to monitor the client's respiratory status. When administering opioids like morphine sulfate via a PCA pump, it is crucial to closely monitor the client's respiratory status to detect signs of respiratory depression early. This is important for ensuring the client's safety while receiving pain management. Choices B, C, and D are incorrect because while teaching the client to use the PCA pump and assessing or evaluating their pain level are essential aspects of care, monitoring respiratory status takes precedence due to the potential risks associated with opioid use.

3. A client admitted to the hospital for depression is escorted to a private room. Prior to leaving the room, what intervention is most important for the nurse to implement?

• A. Explain the program's guidelines
• B. Search all personal belongings
• C. Initiate psychosocial assessment
• D. Review the healthcare provider's prescription

Correct answer: B

Rationale: Searching personal belongings is essential to ensure the safety of the client by preventing access to items that could be used for self-harm. While explaining the program's guidelines (Choice A) and initiating a psychosocial assessment (Choice C) are important aspects of care, the immediate concern in this situation is the safety of the client. Reviewing the healthcare provider's prescription (Choice D) is important for providing appropriate treatment but is not as urgent as ensuring the client's safety.

4. A male client is admitted to the mental health unit because he experiences panic attacks when driving on the freeway. To attempt to desensitize this fear, what action should the nurse encourage the client to implement?

• A. Watch training videos of people driving in various environments
• B. Begin visualizing himself driving each route to the freeway
• C. Take antianxiety medication two hours before driving on freeways
• D. Get in the car with a support person and drive on a freeway during rush hour

Correct answer: B

Rationale: Visualization techniques, such as visualizing himself driving each route to the freeway, are commonly used in desensitization therapy to help clients gradually overcome their fears. Watching videos of others driving or taking medication do not actively involve the client in facing their fear, which is essential in desensitization therapy. Getting in the car with a support person during rush hour may exacerbate the client's anxiety rather than help in desensitization.

5. A client who has a flaccid bladder is placed on a bladder training program. Which instruction should the nurse include in this client's teaching plan?

• A. Use manual pressure to express urine
• B. Perform the Crede maneuver
• C. Apply an external urinary drainage device
• D. Take a warm sitz bath twice a day

Correct answer: B

Rationale: The correct answer is B: Perform the Crede maneuver. The Crede maneuver is a technique used to manage a flaccid bladder by applying manual pressure over the bladder area to assist in the expulsion of urine. This technique helps promote bladder emptying. Choice A is incorrect because using manual pressure to express urine is not a standardized technique and may cause harm. Choice C is incorrect as applying an external urinary drainage device does not address the need for bladder training. Choice D is unrelated to bladder training for a flaccid bladder.

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