Nursing Elites

1. A client with staphylococcus epidermidis is prescribed vancomycin. Identify the adverse effect associated with this antibiotic therapy.

• A. Hepatotoxicity
• B. Constipation
• C. Infusion reaction
• D. Immunosuppression

Correct answer: C

Rationale: The correct adverse effect associated with vancomycin therapy is an infusion reaction, known as Red Man Syndrome. This reaction presents with rashes, flushing, tachycardia, and hypotension. It is essential to administer vancomycin over at least 60 minutes to prevent these symptoms. Hepatotoxicity, constipation, and immunosuppression are not commonly associated with vancomycin use. Ototoxicity and renal toxicity are significant risks with prolonged vancomycin therapy.

2. A nurse is assessing a client who has diabetes insipidus and is receiving desmopressin. Which of the following should the nurse monitor?

• A. Fasting blood glucose
• B. Carbohydrate intake
• C. Hematocrit
• D. Weight

Correct answer: D

Rationale: The correct answer is D: Weight. Desmopressin can cause fluid retention, so monitoring the client's weight is crucial to detect signs of water intoxication or overhydration, which can occur with the medication. Monitoring fasting blood glucose (choice A) is not directly related to desmopressin use in diabetes insipidus. Carbohydrate intake (choice B) is important for diabetes management but is not specifically relevant to monitoring desmopressin therapy. Hematocrit (choice C) is not typically influenced by desmopressin use in diabetes insipidus.

3. A nurse is assessing a newborn who was born vaginally with vacuum extractor assistance. The nurse notes swelling over the newborn's head that crosses the suture line. The nurse should identify the swelling as which of the following findings?

• A. Nevus simplex
• B. Caput succedaneum
• C. Cephalohematoma
• D. Erythema toxicum

Correct answer: B

Rationale: Caput succedaneum is the correct answer. It is the swelling of the soft tissues of the head that crosses suture lines, often resulting from pressure during delivery, especially with vacuum extraction. Nevus simplex (Choice A) is a pink or red birthmark that is flat and usually fades on its own. Cephalohematoma (Choice C) is a collection of blood between a baby's skull and the periosteum, often caused by birth trauma. Erythema toxicum (Choice D) is a common rash in newborns that is benign and typically resolves on its own. In this case, the description of swelling over the newborn's head crossing the suture line is characteristic of caput succedaneum, which is a common finding in newborns after vaginal delivery.

4. A patient is scheduled for cataract surgery but decides to cancel, stating 'I see just fine.' Which of the following responses should the nurse make?

• A. That’s not a good idea; the surgery is necessary
• B. Share with me more about the thoughts that are concerning you
• C. You should trust your doctor’s advice
• D. You can always reschedule the surgery later

Correct answer: B

Rationale: The correct response is to encourage the patient to share more about their concerns. This approach helps the nurse understand the patient's perspective and allows for a supportive discussion. Choice A is dismissive and does not address the patient's feelings. Choice C may undermine the patient's autonomy and decision-making. Choice D suggests delaying without addressing the patient's current decision.

5. A nurse is caring for a client who has chronic kidney disease. Which of the following diets should the nurse anticipate the provider to prescribe?

• A. 4 g sodium diet
• B. Potassium-restricted diet
• C. High phosphorus diet
• D. High protein diet

Correct answer: B

Rationale: Clients with chronic kidney disease often have difficulty regulating potassium levels in their blood. A potassium-restricted diet helps prevent hyperkalemia, a common complication in these clients. High sodium diet (Choice A) is typically avoided in kidney disease to prevent fluid retention and high blood pressure. High phosphorus diet (Choice C) is usually restricted in kidney disease as elevated phosphorus levels can lead to bone and heart problems. While protein is important for overall health, a high protein diet (Choice D) can put extra strain on the kidneys and is usually limited in chronic kidney disease.

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