Nursing Elites

1. A nurse is teaching a group of clients about measures to prevent the development of skin cancer. Which of the following client statements indicates a need for further teaching?

• A. I will avoid going outside between 1000 and 1600.
• B. I will wear a wide-brimmed hat when I go outside.
• C. I will make sure to apply sunscreen with SPF 10 when I’m in the sun.
• D. I will reapply my sunscreen every 2 hours.

Correct answer: C

Rationale: The correct answer is C. An SPF of at least 15 is recommended to effectively protect against harmful UV rays. A sunscreen with an SPF of 10 is insufficient and does not provide adequate protection against skin cancer. Choices A, B, and D demonstrate good understanding of sun protection measures, such as avoiding peak sun hours, wearing protective clothing like a wide-brimmed hat, and reapplying sunscreen every 2 hours, which are all effective strategies to prevent skin cancer.

2. A healthcare professional is assessing a client in the PACU. Which finding indicates decreased cardiac output?

• A. Shivering
• B. Oliguria
• C. Bradypnea
• D. Constricted pupils

Correct answer: B

Rationale: The correct answer is B: Oliguria. Oliguria (low urine output) is a sign of decreased cardiac output because the kidneys are not receiving enough blood to produce an adequate amount of urine. Shivering (choice A) is a response to hypothermia or the body's attempt to generate heat. Bradypnea (choice C) refers to abnormally slow breathing rate and is not directly related to cardiac output. Constricted pupils (choice D) are more indicative of conditions affecting the nervous system or medications.

3. 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.

4. A client is experiencing urinary incontinence, and a nurse is providing care. Which of the following recommendations should the nurse include in the teaching plan for this client?

• A. Drink large amounts of water before bedtime
• B. Perform Kegel exercises regularly
• C. Limit fiber intake in the diet to avoid bowel irritation
• D. Increase intake of caffeinated and carbonated beverages

Correct answer: B

Rationale: The correct recommendation for a client experiencing urinary incontinence is to perform Kegel exercises regularly. These exercises help strengthen the pelvic floor muscles, improving bladder control and reducing urinary incontinence. Option A is incorrect because drinking large amounts of water before bedtime can worsen urinary incontinence by increasing urine production. Option C is incorrect as fiber is important for bowel health and limiting it may not be beneficial for the client. Option D is incorrect as caffeinated and carbonated beverages can irritate the bladder and worsen urinary incontinence, so they should be avoided.

5. A nurse is caring for a newborn in the nursery following a circumcision. The newborn's grandparent, who does not have an identification bracelet, requests to take the newborn to his mother's room. What action should the nurse take?

• A. Notify security.
• B. Respectfully deny the grandparent’s request.
• C. Contact the mother for verification.
• D. Escort the grandparent and newborn to the room.

Correct answer: B

Rationale: The correct action for the nurse to take is to respectfully deny the grandparent's request. In healthcare settings, strict security protocols are in place to ensure the safety of newborns. Only individuals with proper identification bracelets are allowed to transport newborns to prevent unauthorized individuals from taking them. Contacting the mother for verification would be time-consuming and may not be feasible immediately. Escorting the grandparent and newborn without proper identification would violate security protocols and compromise the newborn's safety. Notifying security should be done only if there is a threat or concern for safety, which is not the case in this scenario. Therefore, the best course of action is for the nurse to respectfully deny the grandparent's request to uphold the safety and security measures in place.

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