Nursing Elites

1. A nurse is caring for a client who has a urinary tract infection (UTI) and is prescribed ciprofloxacin. The nurse should instruct the client to monitor for and report which of the following adverse effects?

• A. Tinnitus.
• B. Photosensitivity.
• C. Urinary frequency.
• D. Insomnia.

Correct answer: B

Rationale: The correct answer is B: Photosensitivity. Ciprofloxacin, an antibiotic commonly used to treat UTIs, can cause photosensitivity as an adverse effect. This reaction makes the skin more sensitive to sunlight, potentially leading to severe sunburns or skin damage. It is crucial for the client to be aware of this adverse effect to take precautions and report any signs of photosensitivity promptly. Choices A, C, and D are incorrect because tinnitus, urinary frequency, and insomnia are not typically associated with ciprofloxacin use. While urinary frequency might be a symptom of UTI, it is not an adverse effect of the medication itself.

2. How should a healthcare professional manage a patient with fluid overload in heart failure?

• A. Monitor daily weight
• B. Check for edema
• C. Monitor intake and output
• D. Administer diuretics

Correct answer: A

Rationale: Monitoring daily weight is crucial in managing a patient with fluid overload in heart failure. Weight fluctuations can indicate fluid retention or loss, guiding healthcare professionals in adjusting treatment. While checking for edema (Choice B) and monitoring intake and output (Choice C) are important aspects of patient care, they are not as direct in assessing fluid overload as daily weight monitoring. Administering diuretics (Choice D) is a treatment option based on the assessment of fluid overload, making it a secondary intervention compared to monitoring weight.

3. A nurse is caring for a client who is receiving enteral feedings through a nasogastric tube. Which of the following findings should the nurse report to the provider?

• A. Gastric residual of 200 mL or more
• B. pH of gastric contents is 5.0
• C. Bowel sounds are present in all quadrants
• D. Temperature 37.5°C (99.5°F)

Correct answer: A

Rationale: The correct answer is A. A gastric residual of 200 mL or more indicates delayed gastric emptying, which can be a sign of potential complications such as aspiration or intolerance to the enteral feedings. This finding should be reported to the healthcare provider for further evaluation and possible intervention. Choices B, C, and D are within normal limits and do not require immediate reporting. A pH of 5.0 is normal for gastric contents, bowel sounds in all quadrants indicate normal gastrointestinal motility, and a temperature of 37.5°C (99.5°F) is within the normal range.

4. A patient refused a newly open fentanyl patch. Which of the following actions should the nurse take?

• A. Ask another nurse to witness the disposal of the new patch
• B. Dispose of the patch in a sharps container
• C. Send the patch back to the pharmacy
• D. Document the refusal and remove the patch

Correct answer: A

Rationale: The correct action for the nurse to take when a patient refuses a newly open fentanyl patch is to ask another nurse to witness the disposal of the new patch. This is essential for accountability and ensuring proper disposal procedures are followed. Choice B is incorrect because disposing of the patch in a sharps container without a witness does not ensure proper accountability. Choice C is incorrect as sending the patch back to the pharmacy is not the appropriate action for disposal. Choice D is incorrect because although documenting the refusal is important, it is also crucial to ensure proper disposal of the unused patch by having another nurse witness it.

5. A client at 32 weeks of gestation with preeclampsia is receiving teaching from a nurse. Which statement by the client indicates an understanding of the teaching?

• A. I will take a daily aspirin to prevent blood clots.
• B. I will call my provider if I experience swelling in my hands.
• C. I should increase my calcium intake to prevent seizures.
• D. I will restrict my protein intake to prevent further kidney damage.

Correct answer: B

Rationale: The correct answer is B because swelling in the hands is a potential sign of worsening preeclampsia, and the client should report this to their provider. Choice A is incorrect since aspirin is not recommended in preeclampsia. Choice C is incorrect as calcium intake is not directly related to preventing seizures in preeclampsia. Choice D is incorrect because protein restriction is not the standard management for preventing further kidney damage in preeclampsia.

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