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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The nurse is caring for a client who has type 2 diabetes mellitus and an elevated hemoglobin A1c. Which statement by the nurse will best address this result?
- A. It is important for us to review the signs and symptoms of a hypoglycemic reaction.
- B. Let's review your diet, exercise, and medication regimen over the past 2-3 months.
- C. Please describe what you have eaten in the last 24-48 hours.
- D. You should fast for at least 8 hours prior to your morning blood work.
Correct Answer: B
Rationale: Elevated A1c reflects poor glycemic control over months, so reviewing diet, exercise, and medications is most relevant. Other options are less comprehensive.
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.
The nurse is making a home visit to the mother of an 8-lb baby boy born five days ago. Which observation indicates that the mother understands the care of the newborn?
- A. The mother is concerned about the fact that the baby has a soft stool after every breast feeding.
- B. The mother gives the baby a sponge bath but does not put him in a tub.
- C. The mother cleans the circumcised penis with alcohol when changing the diaper.
- D. The mother nurses the baby hourly.
Correct Answer: B
Rationale: Sponge baths are appropriate for newborns until the umbilical cord falls off, indicating proper care. Soft stools are normal, alcohol may irritate circumcision sites, and hourly nursing is excessive.
A client with atrial fibrillation is being discharged home after being stabilized with medications, including digoxin. Which client statement regarding digoxin toxicity indicates that reinforcement of the discharge education is needed?
- A. I must visit my health care provider to check my drug levels.
- B. I should report to my health care provider if I develop nausea and vomiting.
- C. I should tell my health care provider if my heart rate is below 60 beats per minute.
- D. I will need to increase my potassium intake.
Correct Answer: D
Rationale: Increasing potassium intake is incorrect and risky with digoxin, as it can affect drug levels. Other statements reflect correct understanding.
The parent of an 8-year-old client asks the nurse for guidance on how to help the client cope with the recent death of the other parent. When developing a response to the parent, the nurse considers that a school-aged child is most likely to do what?
- A. React anxiously to altered daily routines
- B. Realize that death eventually affects everyone
- C. Think about the religious or spiritual aspects of death
- D. Understand that death is permanent but be curious about it
Correct Answer: D
Rationale: School-aged children (around 8 years old) typically understand death's permanence and may exhibit curiosity about it, which can guide coping strategies. A is more common in younger children. B and C are more typical of adolescents, who have more abstract thinking.