A nurse is assisting with the care of a client who has pneumonia.

Exhibits

For each potential nursing action, click to specify if the potential action is. anticipated or contraindicated for the client.

Choice A rationale:

"This medication can increase your risk for sunburn." Ciprofloxacin, a fluoroquinolone antibiotic, can increase the risk of sunburn and photosensitivity reactions. Patients taking this medication should be advised to use sunscreen, wear protective clothing, and avoid excessive sun exposure to prevent sunburn.

Choice B rationale:

"Take an antacid if the medication causes gastrointestinal upset." Ciprofloxacin should not be taken with antacids or other products containing calcium, magnesium, aluminum, or iron, as these can interfere with its absorption. Therefore, advising the patient to take an antacid with ciprofloxacin is incorrect.

Choice C rationale:

"Restrict your daily fluid intake while taking this medication." There is no need to restrict fluid intake while taking ciprofloxacin. In fact, it is important for patients to stay well-hydrated to prevent potential side effects like crystalluria. Adequate fluid intake helps dilute the urine and reduce the risk of crystal formation.

Choice D rationale:

"Expect to experience diarrhea while taking this medication." Diarrhea can be a side effect of ciprofloxacin, but it is not something patients should necessarily expect. While gastrointestinal upset is a known side effect, not everyone who takes the medication will experience diarrhea. Patients should be advised to report any severe or persistent diarrhea to their healthcare provider.

Here are some possible answers: Response to other clients: This finding could indicate that the client’s condition has improved if they are more cooperative and respectful of others, or that it has declined if they are more hostile and paranoid of others. Sleep patterns: This finding could indicate that the client’s condition has improved if they are sleeping more regularly and peacefully, or that it has declined if they are sleeping less or having nightmares.

Hygiene patterns: This finding could indicate that the client’s condition has improved if they are taking care of their personal hygiene and appearance, or that it has declined if they are neglecting or refusing to do so. Interaction with the nurse: This finding could indicate that the client’s condition has improved if they are more trusting and communicative with the nurse, or that it has declined if they are more suspicious and withdrawn from the nurse.