Nursing Elites

1. The nurse is preparing to give a dose of a cephalosporin medication to a patient who has been receiving the antibiotic for 2 weeks. The nurse notes ulcers on the patient’s tongue and buccal mucosa. Which action will the nurse take?

• A. Hold the drug and notify the provider.
• B. Obtain an order to culture the oral lesions.
• C. Gather emergency equipment to prepare for anaphylaxis.
• D. Report a possible superinfection side effect of the cephalosporin.

Correct answer: D

Rationale: The nurse should report a possible superinfection side effect of the cephalosporin to the physician as the patient's symptoms may indicate a superinfection that requires treatment. Holding the drug is not necessary unless directed by the provider. Culturing the lesions is not indicated for this situation. There is no evidence to suggest impending anaphylaxis based on the patient's symptoms.

2. What is the most common symptom of gastroesophageal reflux disease (GERD)?

• A. Heartburn.
• B. Nausea.
• C. Abdominal pain.
• D. Vomiting.

Correct answer: A

Rationale: The correct answer is A: Heartburn. Heartburn is the most common symptom of GERD as it occurs due to the reflux of stomach acid into the esophagus. This leads to a burning sensation in the chest that can worsen after eating, lying down, or bending over. Choice B, Nausea, is not typically the most common symptom of GERD, although it can occur in some cases. Choice C, Abdominal pain, is not a primary symptom of GERD and is more commonly associated with other gastrointestinal conditions. Choice D, Vomiting, is also not the most common symptom of GERD, although it can occur in severe cases or as a result of complications.

3. A client has pyelonephritis and expresses embarrassment about discussing symptoms. How should the nurse respond?

• A. Assure the client that their symptoms will be kept confidential.
• B. Acknowledge the client's discomfort and avoid discussing elimination topics.
• C. Encourage the use of familiar language and assure the client they can take their time.
• D. Offer the client a nurse of the same gender to provide care.

Correct answer: C

Rationale: When a client expresses embarrassment or discomfort in discussing symptoms related to sensitive topics like elimination and the genitourinary area, the nurse should respond by encouraging the client to use words they are comfortable with. This helps the client feel more at ease and opens up communication. Offering a nurse of the same gender may not address the client's discomfort with discussing symptoms. Assuring confidentiality is important, but it should not be promised in a way that may not be fulfilled. Avoiding the topic of elimination entirely does not address the client's feelings or promote effective communication.

4. A client with Herpes Zoster (shingles) on the thorax tells the nurse about having difficulty sleeping. What is the probable cause of this problem?

• A. Frequent cough
• B. Pain
• C. Nocturia
• D. Dyspnea

Correct answer: B

Rationale: The correct answer is B: Pain. Pain is a common and significant symptom of Herpes Zoster (shingles) that can result in difficulty sleeping. The pain associated with shingles can be intense and persistent, making it challenging for the client to find a comfortable position to sleep. Nocturia (choice C), which is excessive urination during the night, is not directly related to difficulty sleeping in this context. While both frequent cough (choice A) and dyspnea (choice D) can cause sleep disturbances, in a client with Herpes Zoster on the thorax, pain is the most probable cause of sleep difficulty.

5. A healthcare professional is monitoring the respiratory status of a client who has just undergone surgery and is wearing a pulse oximeter. Which of the following coexisting problems is cause for the healthcare professional to suspect that the oxygen saturation readings are not entirely accurate?

• A. Infection
• B. Hypertension
• C. Low blood pressure
• D. Loss of cough reflex

Correct answer: C

Rationale: Low blood pressure (hypotension), shock, and the use of peripheral vasoconstricting medications can lead to inaccurate pulse oximetry readings due to impaired peripheral perfusion. Hypertension and infection are not typically associated with inaccurate pulse oximetry readings, while the loss of cough reflex does not directly affect oxygen saturation readings.

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