Nokea
A client is receiving erythromycin 500 mg IV every 6 hours to treat a pneumonia. Which of the following is the most common side effect of the medication?
- A. Blurred vision
- B. Nausea and vomiting
- C. Severe headache
- D. Insomnia
Correct Answer: B
Rationale: Nausea and vomiting. Nausea is a common side-effect of erythromycin in both oral and intravenous forms.
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The client with arthritis is self-medicating with aspirin, a nonsteroidal anti-inflammatory medication. Which complication should the nurse discuss with the client?
- A. Tinnitus.
- B. Diarrhea.
- C. Tetany.
- D. Paresthesia.
Correct Answer: A
Rationale: High-dose aspirin can cause tinnitus, an early sign of salicylate toxicity, requiring education. Diarrhea, tetany, or paresthesia are less common.
The HCP has ordered an intramuscular antibiotic. After reconstituting the medication, the clinic nurse must administer 4.8 mL of the medication. Which action should the nurse implement first when administering this medication?
- A. Inform the HCP the amount of medication is too large.
- B. Administer the medication in the gluteal muscle.
- C. Discard the medication in the sharps container.
- D. Divide the medication and give 2.4 mL in each hip.
Correct Answer: D
Rationale: IM injections >3 mL should be divided; 2.4 mL in each hip (gluteal) ensures safe absorption. Notifying HCP, single-site injection, or discarding are incorrect.
A 66 year-old client is admitted for mitral valve replacement surgery. The client has a history of mitral valve regurgitation and mitral stenosis since her teenage years. During the admission assessment, the nurse should ask the client if as a child she had
- A. measles
- B. rheumatic fever
- C. hay fever
- D. encephalitis
Correct Answer: B
Rationale: rheumatic fever. Clients that present with mitral stenosis often have a history of rheumatic fever or bacterial endocarditis.
An adult client has pulmonary tuberculosis. He is receiving isoniazid (INH) 300 mg PO, ethambutol 1 g PO daily, and streptomycin 1 g IM three times a week. When he comes in for a checkup, he tells the nurse that he hates getting shots and his ears ring most of the time. What is the best interpretation for the nurse to make regarding the client's complaints?
- A. He may be receiving too much ethambutol.
- B. He should be evaluated for adverse reaction to streptomycin.
- C. Tuberculosis may have spread to the brain.
- D. He is experiencing a reaction commonly seen when INH and streptomycin are given at the same time.
Correct Answer: B
Rationale: Streptomycin is ototoxic, and ringing in the ears (tinnitus) is a sign of potential eighth cranial nerve damage, requiring evaluation.
The elderly male client is admitted for acute severe diverticulitis. He has been taking Xanax, a benzodiazepine, for nervousness three (3) to four (4) times a day prn for six (6) years. Which intervention should the nurse implement first?
- A. Prepare to administer an intravenous antianxiety medication.
- B. Notify the HCP to obtain an order for the client's Xanax prn.
- C. Explain Xanax causes addiction and he should quit taking it.
- D. Assess for signs/symptoms of medication withdrawal.
Correct Answer: D
Rationale: Long-term Xanax use risks dependence; assessing withdrawal (e.g., agitation, seizures) is the priority during acute illness to guide safe management.