Nursing Elites

1. Which of the following adverse effects should the client on Floxin be alerted to?

• A. stunting of height in teens and young adults
• B. propensity for anovulatory uterine bleeding
• C. intractable diarrhea
• D. tendon rupture

Correct answer: D

Rationale: The correct answer is tendon rupture. Floxin is a quinolone antibiotic commonly used in respiratory infections and pelvic/reproductive infections. One of the rare adverse effects associated with quinolones is tendon sheath rupture, often affecting the Achilles tendon. Therefore, patients taking Floxin should be alerted to the possibility of tendon rupture. Choices A, B, and C are incorrect as they are not typically associated with Floxin use and are not common adverse effects of quinolone antibiotics. Stunting of height is not a recognized adverse effect of Floxin. Anovulatory uterine bleeding is not a known side effect of quinolones. Intractable diarrhea is not a common adverse effect of Floxin.

2. A case manager is reviewing the records of the clients in the nursing unit. Which note(s) in a client's record indicate an unexpected outcome and the need for follow-up?

• A. A client is performing their own colostomy irrigations.
• B. A client with a central venous catheter has a temperature of 100.6�F.
• C. A client who has just undergone surgery has a urine output of more than 30 mL/hr.
• D. A client with a new diagnosis of diabetes mellitus is self-administering insulin.

Correct answer: B

Rationale: A case manager is a healthcare professional responsible for coordinating a client's care from admission through and after discharge. They evaluate and update the plan of care as needed, monitoring for unexpected outcomes and providing follow-up. A temperature of 100.6�F in a client with a central venous catheter is an unexpected outcome that requires follow-up due to the potential indication of an infection. Choices A, C, and D describe expected outcomes and appropriate self-care management. The client self-irrigating their colostomy, a post-surgical client having adequate urine output, and a newly diagnosed diabetic self-administering insulin are all positive indicators of self-care and expected outcomes, not requiring immediate follow-up.

3. The nurse has completed client teaching about introducing solid foods to an infant. To evaluate teaching, the nurse asks the mother to identify an appropriate first solid food. Which of the following is an appropriate response?

• A. pureed canned squash
• B. pureed apples
• C. yogurt
• D. infant rice cereal

Correct answer: D

Rationale: The correct answer is infant rice cereal. Single-grain infant cereals are recommended as the first solid food because they are easily digestible and have added iron content. Choice C, yogurt, is incorrect because yogurt is a milk product and should be delayed until the child is 12 months old due to the risk of milk allergy. Choices A and B are incorrect because fruits and vegetables are typically introduced after cereals to help the infant get accustomed to solid foods gradually.

4. The nurse in the emergency room is admitting a client who has sustained a gunshot wound and will require immediate surgery. The client is unconscious and by themselves. Which of the following actions is most appropriate?

• A. Call the charge nurse and request that the facility's legal counsel provide a waiver for informed consent.
• B. Attempt to stabilize the client in the emergency room until they are conscious enough to provide informed consent.
• C. Try to locate the client's family to obtain informed consent before transporting the client to the operating room.
• D. Proceed with transporting the client to the operating room without obtaining informed consent.

Correct answer: D

Rationale: In emergency situations where a client is unconscious and requires immediate surgery to save their life, the priority is to proceed with necessary interventions without delay to ensure the best possible outcome. Obtaining informed consent is essential in healthcare, but in situations where a delay in treatment can be life-threatening, healthcare providers are ethically and legally permitted to proceed with treatment without consent. Attempting to stabilize the client until conscious enough to provide consent or trying to locate family members for consent would cause a dangerous delay in critical care. Therefore, the most appropriate action in this scenario is to transport the unconscious client to the operating room for immediate surgery.

5. Which of the following foods present a problem for a client diagnosed with Celiac Disease?

• A. butter
• B. oats or barley cereal
• C. fresh vegetables
• D. coffee or tea

Correct answer: B

Rationale: Celiac disease, also known as celiac sprue, is a malabsorption disorder affecting the small intestine due to a problem with ingesting gluten, a protein found in wheat, rye, oats, and barley. Therefore, oats or barley cereal would present a problem for a client with Celiac Disease as they contain gluten. Fresh vegetables, butter, coffee, and tea, on the other hand, do not contain gluten and should not pose any issues for individuals with this disorder. Therefore, the correct answer is oats or barley cereal. Choices A, C, and D are not problematic for clients with Celiac Disease as they are gluten-free.

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