Nursing Elites

1. A new mother asks the clinic nurse if she must continue giving her baby nystatin for thrush since the white lesions on his tongue have disappeared. What response by the nurse is most appropriate?

• A. No. When the lesions have disappeared, you may stop the nystatin.
• B. Yes. You should continue it for the full 7 days.
• C. No. Thrush is a self-limiting disorder, and nystatin is given for complete treatment.
• D. Yes. The medication should be refilled for a second week of therapy.

Correct answer: B

Rationale: The correct answer is B because nystatin should be given for the full 7 days even if the lesions are no longer present. Continuing the treatment for the prescribed duration ensures complete eradication of the fungal infection. Choice A is incorrect as stopping the medication prematurely may lead to the reoccurrence of thrush. Choice C is inaccurate as nystatin is not just for comfort but for effective treatment. Choice D is incorrect as refilling the medication for a second week without medical advice may lead to unnecessary prolonged use and potential side effects.

2. An adolescent female asks the nurse about taking retinoic acid (Accutane). What guidance should be provided by the nurse?

• A. The medication should be used for 10 weeks only.
• B. The medication requires that sexually active females use contraception.
• C. The medication lowers hemoglobin levels very quickly.
• D. The medication has few side effects.

Correct answer: B

Rationale: The correct guidance the nurse should provide is that sexually active females must use contraception while taking Accutane and for 1 month after the 20 weeks it is prescribed. Choice A is incorrect because Accutane is typically taken for a longer duration than 10 weeks. Choice C is incorrect because Accutane does not lower hemoglobin levels quickly. Choice D is incorrect as Accutane is known for having many side effects, including the risk of birth defects.

3. Which finding should the nurse report immediately for a client receiving a blood transfusion?

• A. Mild itching and rash
• B. Temperature increase of 1.5°F (0.8°C)
• C. Heart rate increase of 10 beats per minute
• D. Slight headache

Correct answer: B

Rationale: A temperature increase of 1.5°F (0.8°C) during a blood transfusion is a significant finding that can indicate a transfusion reaction, such as a febrile non-hemolytic reaction, which can progress to more severe reactions. It is crucial to report this immediately to the healthcare provider for further evaluation and intervention. Mild itching and rash (choice A) are common minor reactions to blood transfusions and can be managed appropriately without immediate concern. An increase in heart rate by 10 beats per minute (choice C) is within an acceptable range and may be a normal compensatory response to the transfusion. A slight headache (choice D) is a common complaint and is not typically associated with severe transfusion reactions; thus, it does not require immediate reporting compared to the temperature increase.

4. Parents of a school-age child ask the nurse for suggestions in helping the child who is demonstrating school avoidance. What is an appropriate suggestion by the nurse?

• A. Take the child to the healthcare provider for testing.
• B. Be firm and insist the child go to school.
• C. Allow the child to stay home and rest.
• D. Consult with the teacher at school.

Correct answer: B

Rationale: When a child is demonstrating school avoidance, it is important for parents to be firm and insist that the child go to school. This helps establish a routine and prevents the behavior from becoming a pattern. Taking the child to the healthcare provider for testing (Choice A) may not be necessary at this stage as school avoidance is a behavioral issue. Allowing the child to stay home and rest (Choice C) may reinforce the avoidance behavior. While consulting with the teacher at school (Choice D) is important, the immediate focus should be on addressing the avoidance behavior at home.

5. A client with a history of seizures is prescribed phenytoin. Which side effect should the nurse instruct the client to report?

• A. Drowsiness
• B. Gingival hyperplasia
• C. Weight gain
• D. Blurred vision

Correct answer: B

Rationale: The correct answer is B: Gingival hyperplasia. Phenytoin is known to cause gingival hyperplasia, which is an overgrowth of gum tissue. This side effect is important to report to the healthcare provider because it can lead to oral health problems. Choice A, drowsiness, is a common side effect of many antiepileptic drugs but is not specific to phenytoin. Choice C, weight gain, is not a typical side effect of phenytoin. Choice D, blurred vision, is not a common side effect of phenytoin; it is more commonly associated with other medications.

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