Nokea
A client is receiving vancomycin (Vancocin). Which of the following is the most important action for the nurse to take?
- A. Monitor the client for signs of nephrotoxicity.
- B. Monitor the client for signs of ototoxicity.
- C. Ensure adequate hydration.
- D. Administer the medication with food.
Correct Answer: A
Rationale: The most important action for the nurse to take when a client is receiving vancomycin is to monitor for signs of nephrotoxicity. Vancomycin can cause kidney damage, so monitoring kidney function and signs of nephrotoxicity are crucial to prevent harm. While monitoring for ototoxicity and ensuring adequate hydration are important nursing actions, they are not as critical as preventing nephrotoxicity when administering vancomycin.
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Carbamazepine (Tegretol) is prescribed for a client with a diagnosis of psychomotor seizures. The nurse reviews the client's health history, knowing that this medication is contraindicated if which of the following disorders is present?
- A. Headaches
- B. Liver disease
- C. Hypothyroidism
- D. Diabetes mellitus
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Oxybutynin chloride (Ditropan XL) is prescribed for a client with neurogenic bladder. Which sign would indicate a possible toxic effect related to this medication?
- A. Pallor
- B. Drowsiness
- C. Bradycardia
- D. Restlessness
Correct Answer: D
Rationale: Signs of toxicity related to oxybutynin chloride (Ditropan XL) include central nervous system excitation, such as nervousness, restlessness, hallucinations, and irritability. Other signs of toxicity may include hypotension or hypertension, confusion, tachycardia, a flushed or red face, and signs of respiratory depression. Restlessness is a sign of central nervous system excitation, which can indicate a possible toxic effect of this medication.
A client is being taught about the use of nitroglycerin (Nitrostat) for angina. Which statement by the client indicates a need for further teaching?
- A. I will sit or lie down when I take the medication.
- B. I can take up to three tablets, 5 minutes apart, if needed.
- C. I will call 911 if my chest pain is not relieved after taking three tablets.
- D. I will keep the medication in its original dark container.
Correct Answer: B
Rationale: The correct administration of nitroglycerin for angina is to take up to three tablets, 5 minutes apart. If the chest pain persists after the third tablet, emergency medical services should be called. Taking more than three tablets or reducing the time interval between doses may lead to hypotension and indicates a need for further teaching.
Desmopressin acetate (DDAVP) is prescribed for the treatment of diabetes insipidus. The nurse monitors the client after medication administration for which therapeutic response?
- A. Decreased urinary output
- B. Decreased blood pressure
- C. Decreased peripheral edema
- D. Decreased blood glucose level
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A nurse reinforces discharge instructions to a postoperative client who is taking warfarin sodium (Coumadin). Which statement, if made by the client, reflects the need for further teaching?
- A. I will take my pills every day at the same time.
- B. I will be certain to avoid alcohol consumption.
- C. I have already called my family to pick up a Medic-Alert bracelet.
- D. I will take Ecotrin (enteric-coated aspirin) for my headaches because it is coated.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.