Nursing Elites

1. A patient has a history of photosensitive reactions to medications. Which of the following drugs is associated with photosensitive reactions? Select one that doesn't apply

• A. Ciprofloxacin (Cipro)
• B. Sulfonamide
• C. Norfloxacin (Noroxin)
• D. Nitro-Dur patch

Correct answer: D

Rationale: Nitro-Dur patch is not associated with photosensitive reactions. It is used to prevent chest pain or angina, and common side effects include headache, lightheadedness, nausea, and flushing. Choices A, B, and C are known to cause photosensitive reactions. Ciprofloxacin (Cipro), Sulfonamides, and Norfloxacin (Noroxin) are drugs that are commonly associated with photosensitivity reactions. Patients taking these medications should be advised to avoid direct sunlight and use sun protection to prevent skin reactions.

2. Mr. C is brought to the hospital with severe burns over 45% of his body. His heart rate is 124 bpm and thready, BP 84/46, respirations 24/minute and shallow. He is apprehensive and restless. Which of the following types of shock is Mr. C at highest risk for?

• A. Septic shock
• B. Hypovolemic shock
• C. Neurogenic shock
• D. Cardiogenic shock

Correct answer: B

Rationale: Mr. C, who has severe burns over 45% of his body, is at highest risk for hypovolemic shock. Burns lead to a loss of plasma volume, reducing the circulating fluid volume and impairing perfusion to vital organs and extremities. In this scenario, the signs of shock, such as increased heart rate, low blood pressure, shallow respirations, and restlessness, indicate a state of hypovolemic shock due to significant fluid loss. Septic shock (choice A) is primarily caused by severe infections, neurogenic shock (choice C) results from spinal cord injuries, and cardiogenic shock (choice D) stems from heart failure. However, in this case, the presentation aligns most closely with hypovolemic shock due to the extensive burn injury and its effects on fluid volume and perfusion.

3. A 38-year-old patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care?

• A. Restrict daily dietary protein intake.
• B. Reposition the patient every 4 hours.
• C. Place the patient on a pressure-relieving mattress.
• D. Perform passive range of motion daily.

Correct answer: C

Rationale: Placing the patient on a pressure-relieving mattress is crucial to decrease the risk of skin breakdown, especially with significant edema and ascites. Adequate dietary protein intake is essential in patients with ascites to improve oncotic pressure and prevent malnutrition. Repositioning the patient every 4 hours alone may not be sufficient to prevent skin breakdown, especially in areas prone to pressure ulcers. Performing passive range of motion exercises is important for maintaining joint mobility but does not directly address the risk of skin breakdown associated with prolonged pressure on vulnerable areas.

4. A patient is undergoing a stress test on a treadmill and turns to talk to the nurse. Which of these statements would require the most immediate intervention?

• A. I'm feeling extremely thirsty and will get some water after this.
• B. I can feel my heart racing.
• C. My shoulder and arm are hurting.
• D. My blood pressure reading is 158/80

Correct answer: C

Rationale: The correct answer is 'C: My shoulder and arm are hurting.' Unilateral arm and shoulder pain are classic symptoms of myocardial ischemia, indicating possible heart issues. In this scenario, immediate intervention is required, and the stress test should be halted. Choice A about feeling thirsty does not indicate an acute medical issue. Choice B mentioning heart racing is expected during a stress test. Choice D, a blood pressure reading of 158/80, while slightly elevated, does not present an immediate concern compared to the symptoms of arm and shoulder pain suggesting cardiac distress.

5. The nurse is reviewing the lab results of a patient taking lithium for schizoaffective disorder. The lab results show that the blood lithium value is 1.7 mcg/L. What would the nurse take as the priority action?

• A. Induce vomiting
• B. Hold the next dose of Lithium
• C. Administer an antiemetic
• D. Give the next dose of Lithium

Correct answer: B

Rationale: The correct answer is to hold the next dose of Lithium. The blood lithium value of 1.7 mcg/L exceeds the therapeutic range of 0.5-1.5 mcg/L, indicating potential toxicity. Holding the next dose is crucial to prevent further accumulation of lithium in the bloodstream. Inducing vomiting is not appropriate in this situation as the priority is to prevent further absorption of lithium. Administering an antiemetic is not the priority in lithium toxicity. Giving the next dose of lithium would exacerbate the toxicity and should be avoided.

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