Nursing Elites

1. When a patient starts taking amoxicillin, which foods should the nurse instruct the patient to avoid?

• A. Green leafy vegetables
• B. Beef and other red meat
• C. Coffee, tea, and colas
• D. Acidic fruits and juices

Correct answer: D

Rationale: The correct answer is D: Acidic fruits and juices. Amoxicillin can be irritating to the stomach, so avoiding acidic fruits and juices is recommended to reduce stomach discomfort or potential interactions. Green leafy vegetables (Choice A), beef and other red meat (Choice B), and coffee, tea, and colas (Choice C) are not typically contraindicated with amoxicillin. It is important to focus on acidic foods and beverages to promote comfort and effectiveness of the medication.

2. A client presents with a urine specific gravity of 1.018. What action should the nurse take?

• A. Evaluate the client’s intake and output for the past 24 hours.
• B. Document the finding in the chart and continue to monitor.
• C. Obtain a specimen for a urine culture and sensitivity.
• D. Encourage the client to drink more fluids, especially water.

Correct answer: B

Rationale: A urine specific gravity of 1.018 falls within the normal range, indicating adequate hydration. Therefore, the appropriate action is to document this finding in the client's chart and continue monitoring. There is no need to evaluate intake and output, as the specific gravity is normal. Obtaining a urine culture and sensitivity or encouraging increased fluid intake is unnecessary in this situation.

3. While assisting a client with a closed chest tube drainage system to move from bed to a chair, the chest tube gets caught on the chair leg and becomes dislodged from the insertion site. What is the immediate priority for the nurse?

• A. Contacting the physician
• B. Reinserting the chest tube
• C. Transferring the client back to bed
• D. Covering the insertion site with a sterile occlusive dressing

Correct answer: D

Rationale: The immediate priority for the nurse when a chest tube becomes dislodged from the insertion site is to cover the site with a sterile occlusive dressing. This action helps prevent air from entering the pleural space, which could lead to a pneumothorax. The nurse should then perform a respiratory assessment to monitor the client's breathing, assist the client back into bed to a position of comfort, and notify the physician. Reinserting the chest tube is a task for the physician, not the nurse, as it requires specific training and expertise.

4. A client with stress incontinence is being taught about pelvic muscle exercises. Which statements should be included by the nurse? (Select all that apply.)

• A. Starting and stopping the urine stream involves using pelvic muscles.
• B. Tighten pelvic muscles for a slow count of 10 and then relax for a slow count of 10.
• C. Pelvic muscle exercises can be performed in various positions: lying down, sitting up, and standing.
• D. A & B

Correct answer: D

Rationale: The correct statements to include when teaching a client with stress incontinence about pelvic muscle exercises are that starting and stopping the urine stream involve using pelvic muscles and that tightening pelvic muscles for a slow count of 10 and then relaxing for a slow count of 10 can help strengthen them. It is essential to highlight that pelvic muscle exercises can be performed in various positions, including lying down, sitting up, and standing. This variety in positions helps engage the muscles effectively. Performing these exercises 15 times in each position can aid in strengthening the pelvic floor muscles. Consistent exercise over several weeks typically leads to improved control over urine leakage. Choice C is incorrect because pelvic muscle exercises can be performed in different positions and are not limited to sitting upright with feet on the floor.

5. The nurse assumes care for a patient who is currently receiving a dose of intravenous vancomycin (Vancocin) infusing at 20 mg/min. The nurse notes red blotches on the patient’s face, neck, and chest and assesses a blood pressure of 80/55 mm Hg. Which action will the nurse take?

• A. Request an order for IV epinephrine to treat anaphylactic shock.
• B. Slow the infusion to 10 mg/min and observe the patient closely.
• C. Stop the infusion and obtain an order for a BUN and serum creatinine.
• D. Suspect Stevens-Johnson syndrome and notify the provider immediately.

Correct answer: B

Rationale: When vancomycin is infused too rapidly, “red man” syndrome may occur; the rate should be 10 mg/min to prevent this. This is a toxic reaction, not an allergic one, so epinephrine is not indicated. Stevens-Johnson syndrome is characterized by a rash and fever. Red man syndrome is not related to renal function.

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