Nursing Elites

1. A client diagnosed with tuberculosis (TB) is placed on drug therapy with rifampin (Rifadin). The client should be instructed to report which effect(s) of the medication to the healthcare provider?

• A. Reddish-orange discoloration of body fluids
• B. Bloody or blood-tinged urine
• C. Blurring of vision
• D. Weight gain of more than 2 pounds in a week

Correct answer: A

Rationale: The correct answer is A. Rifampin (Rifadin) commonly causes a reddish-orange discoloration of body fluids, including urine, sweat, saliva, and tears. This is a harmless side effect but should be reported to the healthcare provider for monitoring. Choices B, C, and D are not typically associated with rifampin therapy. Bloody or blood-tinged urine may indicate other issues such as urinary tract infection or kidney problems, blurring of vision may suggest eye problems, and significant weight gain could be related to various health conditions unrelated to rifampin.

2. Which assessment finding should indicate to the nurse that a client with arterial hypertension is experiencing a cardiac complication?

• A. Complaints of an occipital headache
• B. A palpable dorsal pedis pulse bilaterally
• C. Complaints of shortness of breath on exertion
• D. A blood pressure of 160/90

Correct answer: C

Rationale: The correct answer is C, complaints of shortness of breath on exertion. This symptom is indicative of heart failure, a common cardiac complication of arterial hypertension. Shortness of breath on exertion is often due to the heart's inability to pump effectively, leading to fluid buildup in the lungs. Choices A, B, and D are incorrect because complaints of an occipital headache, a palpable dorsal pedis pulse bilaterally, and a blood pressure of 160/90 do not specifically indicate a cardiac complication in a client with arterial hypertension.

3. An 18-year-old gravida 1, at 41-weeks gestation, is undergoing an oxytocin (Pitocin) induction and has an epidural catheter in place for pain control. With each of the last three contractions, the nurse notes a late deceleration. The client is repositioned and oxygen provided, but the late decelerations continue to occur with each contraction. What action should the nurse take first?

• A. Prepare for immediate cesarean birth
• B. Turn off the oxytocin (Pitocin) infusion
• C. Notify the anesthesiologist that the epidural infusion needs to be disconnected
• D. Apply an internal fetal monitoring device and continue to monitor carefully

Correct answer: B

Rationale: In the scenario described, the presence of late decelerations during contractions indicates fetal compromise. To address this, the nurse's initial action should be to turn off the oxytocin (Pitocin) infusion. Oxytocin can contribute to uteroplacental insufficiency, leading to late decelerations. This intervention aims to improve fetal oxygenation and prevent further stress on the fetus. Immediate cesarean birth is not the first-line action unless other interventions fail. Notifying the anesthesiologist about disconnecting the epidural infusion is not the priority in this situation. Applying an internal fetal monitoring device is invasive and not the immediate step needed when late decelerations are present.

4. The nurse is performing an admission assessment of an older client who has difficulty swallowing and has a history of aspiration pneumonia. Which action should the nurse implement first?

• A. Obtain a speech therapy consult
• B. Elevate the head of the bed
• C. Check the client's lung sounds
• D. Implement aspiration precautions

Correct answer: B

Rationale: The correct action for the nurse to implement first is to elevate the head of the bed. Elevating the head of the bed helps prevent aspiration in clients with swallowing difficulties by reducing the risk of food or fluids entering the airway. While obtaining a speech therapy consult (Choice A) is important, the immediate priority is to ensure the client's safety by positioning them properly. Checking the client's lung sounds (Choice C) and implementing aspiration precautions (Choice D) are also essential steps but should follow the immediate intervention of elevating the head of the bed to prevent aspiration.

5. While teaching a group of adults about health promotion activities, a nurse identifies a behavior that poses the most significant risk factor for the development of skin cancer. Which behavior should the nurse address?

• A. Consuming a high-fat diet
• B. Using tanning beds
• C. Smoking cigarettes
• D. Drinking alcohol

Correct answer: B

Rationale: Using tanning beds is the most significant risk factor for developing skin cancer. Ultraviolet (UV) radiation from tanning beds damages the skin and increases the risk of skin cancer. Consuming a high-fat diet, smoking cigarettes, and drinking alcohol are unhealthy behaviors but are not directly linked to the development of skin cancer like UV exposure from tanning beds.

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