Nokea
A 64-year-old client is prescribed ciprofloxacin for a urinary tract infection. The nurse reminds the client to observe for and notify the health care provider immediately about which of the following?
- A. Brown-colored urine
- B. Hearing and balance problems
- C. Pain in the Achilles tendon area
- D. Sunburn
Correct Answer: C
Rationale: Ciprofloxacin is associated with Achilles tendon rupture, a serious side effect requiring immediate reporting. Other symptoms are less specific.
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A client wanders away from home and is found 48 hours later sleeping on a park bench. The client is awake, alert, and oriented but cannot recall name, address, or events that occurred in the past 2 days. What is the priority nursing action?
- A. Contact family members
- B. Encourage the client to recall recent events
- C. Measure vital signs
- D. Monitor mental status
Correct Answer: C
Rationale: Measuring vital signs is the priority to ensure physiological stability in a client with amnesia, which may indicate a medical emergency like transient global amnesia.
The nurse is measuring the uterine fundal height of a client at 36 weeks gestation lying in a supine position. The client suddenly reports dizziness, and the nurse observes pallor and damp, cool skin. What should the nurse do first?
- A. Alert the supervising registered nurse
- B. Check the client's blood pressure and pulse
- C. Listen to the fetal heart rate
- D. Turn the client to a lateral position
Correct Answer: D
Rationale: Symptoms suggest supine hypotensive syndrome; turning the client to a lateral position relieves uterine pressure on the vena cava, improving blood flow.
The nurse finds a client on the floor in the client's room. Based on the documentation shown in the exhibit, the nurse made an incorrect entry in the client's medical record at what time?
- A. 1700
- B. 1710
- C. 1740
- D. 1810
Correct Answer: C
Rationale: Without specific exhibit details, 1740 is assumed incorrect based on context, possibly due to a documentation error related to the fall. Rationale is limited without exhibit.
An elderly client with depression, diabetes mellitus, and heart failure has received a new digoxin prescription for daily use. Which client assessment indicates that the nurse should follow up on serum digoxin levels frequently?
- A. Apical heart rate is 62/min
- B. Blood sugar level is 240 mg/dL (13.3 mmol/L)
- C. Client is taking 20 mg fluoxetine daily
- D. Serum creatinine is 2.3 mg/dL (203 µmol/L)
Correct Answer: D
Rationale: Elevated serum creatinine (2.3 mg/dL) indicates renal impairment, which can lead to digoxin accumulation, necessitating frequent monitoring.
The nurse is caring for a client with a feeding tube that has become obstructed. Which intervention should the nurse implement first to unclog the tube?
- A. Flush and aspirate the tube with warm water
- B. Instill a digestive enzyme solution into the tube
- C. Instill cola or cranberry juice into the tube
- D. Use a small barrel syringe to flush the tube
Correct Answer: A
Rationale: Flushing with warm water is the first, safest step to unclog a feeding tube. Enzymes or other solutions are used if water fails, and small syringes may cause excessive pressure.