Nursing Elites

1. A nurse is caring for a client who has a urinary tract infection (UTI) and is prescribed ciprofloxacin. The nurse should instruct the client to monitor for and report which of the following adverse effects?

• A. Tinnitus.
• B. Photosensitivity.
• C. Urinary frequency.
• D. Insomnia.

Correct answer: B

Rationale: The correct answer is B: Photosensitivity. Ciprofloxacin, an antibiotic commonly used to treat UTIs, can cause photosensitivity as an adverse effect. This reaction makes the skin more sensitive to sunlight, potentially leading to severe sunburns or skin damage. It is crucial for the client to be aware of this adverse effect to take precautions and report any signs of photosensitivity promptly. Choices A, C, and D are incorrect because tinnitus, urinary frequency, and insomnia are not typically associated with ciprofloxacin use. While urinary frequency might be a symptom of UTI, it is not an adverse effect of the medication itself.

2. A nurse is reviewing the laboratory results of a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse report to the provider?

• A. White blood cell count 6,000/mm3
• B. Positive antinuclear antibody (ANA) titer
• C. Platelet count 220,000/mm3
• D. Blood urea nitrogen (BUN) 15 mg/dL

Correct answer: B

Rationale: A positive antinuclear antibody (ANA) titer is a significant finding in clients with systemic lupus erythematosus (SLE) as it indicates active disease. This result should be reported to the provider for further evaluation and management. Choices A, C, and D are within normal ranges and not specifically indicative of disease activity in SLE. Therefore, they do not require immediate reporting to the provider.

3. A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?

• A. A client who was just given a glass of orange juice for a low blood glucose level.
• B. A client who is scheduled for a procedure in 1 hr.
• C. A client who has 100 mL of fluid remaining in his IV bag.
• D. A client who received a pain medication 30 min ago for postoperative pain.

Correct answer: A

Rationale: A client with low blood glucose levels needs immediate assessment to ensure stabilization. Hypoglycemia can lead to serious complications if not addressed promptly. The other options do not present immediate life-threatening situations that require urgent assessment. Option B can be attended to after addressing the client with low blood glucose levels. Option C can be managed based on the infusion rate and the client's condition. Option D, although important, can be assessed after ensuring the client with low blood glucose levels is stable.

4. A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include?

• A. Excessive sweating.
• B. Increased urinary frequency.
• C. Dry cough.
• D. Metallic taste in the mouth.

Correct answer: A

Rationale: The correct adverse effect of sertraline that the nurse should include in the teaching is excessive sweating. Sertraline is known to cause this side effect in some individuals. Increased urinary frequency (choice B) is not a commonly reported adverse effect of sertraline. Dry cough (choice C) and metallic taste in the mouth (choice D) are also not typically associated with sertraline use. Therefore, the nurse should focus on educating the client about the potential adverse effect of excessive sweating.

5. A patient is scheduled to receive a transfusion of packed RBCs. Which of the following actions should the nurse take?

• A. Prime IV tubing with 0.9% sodium chloride
• B. Use a 24-gauge IV catheter
• C. Obtain filterless IV tubing
• D. Place blood in the warmer for 1 hour

Correct answer: A

Rationale: Priming the IV tubing with 0.9% sodium chloride is crucial before administering packed RBCs as it prevents hemolysis and ensures the safe transfusion of blood. Using a smaller 20- to 22-gauge IV catheter is recommended for packed RBCs to prevent hemolysis due to the small tubing size and faster flow rate. Obtaining filterless IV tubing is incorrect as blood products should be administered through a specialized filter to prevent potential clots or contaminants from reaching the patient. Placing blood in the warmer for an hour is unnecessary and could lead to overheating, potentially causing harm to the patient.

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