Nokea
A client presents with a fungal urinary tract infection (UTI). Which assessments should the nurse complete? (Select all that apply.)
- A. Palpate the kidneys and bladder.
- B. Assess the medical history and current medical problems.
- C. Perform a bladder scan to assess post-void residual.
- D. Inquire about recent travel to foreign countries.
Correct Answer: B
Rationale: When assessing a client with a fungal UTI, the nurse should prioritize gathering information related to the medical history and current medical problems. Clients who are severely immunocompromised or have conditions like diabetes mellitus are more susceptible to fungal UTIs. Assessing the medical history helps identify risk factors and potential causes of the infection. While physical examinations like palpating the kidneys and bladder and performing a bladder scan may be necessary, they should follow the initial assessment of medical history. Inquiring about recent travel to foreign countries is less relevant in the context of a fungal UTI, as the focus should be on immediate medical factors predisposing the client to the infection.
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After an endotracheal tube is placed in a client who experienced sudden onset of respiratory distress, what should the nurse do?
- A. Secure the tube in place with tape
- B. Order a chest x-ray for the client
- C. Document the depth of tube insertion
- D. Auscultate both lungs for breath sounds
Correct Answer: D
Rationale: After endotracheal tube insertion, the nurse should auscultate both lungs for the presence of breath sounds. This step helps confirm proper tube placement and adequate ventilation. Auscultation of breath sounds is crucial to ensure that the tube is correctly positioned in the trachea and not in the esophagus. While securing the tube with tape is important, it is not the immediate priority after insertion. Ordering a chest x-ray may be necessary but is not the first action to take immediately post-intubation. Documenting the depth of tube insertion is important but ensuring proper ventilation through auscultation takes precedence.
The nurse is caring for a 70-kg patient who is receiving gentamicin (Garamycin) 85 mg 4 times daily. The patient reports experiencing ringing in the ears. The nurse will contact the provider to discuss
- A. decreasing the dose to 50 mg QID.
- B. giving the dose 3 times daily.
- C. obtaining a serum drug level.
- D. ordering a hearing test.
Correct Answer: C
Rationale: When a patient receiving gentamicin (Garamycin) reports experiencing ringing in the ears, it is crucial to consider the possibility of ototoxicity. Ototoxicity is a known adverse effect of aminoglycosides. The appropriate action for the nurse in this situation is to contact the provider to discuss obtaining a serum drug level. This is important to assess the drug concentration in the patient's blood, which can help determine if the ringing in the ears is related to the medication. Decreasing the dose or changing the dosing frequency without assessing the serum drug level may not address the underlying issue and could potentially lead to suboptimal treatment. Ordering a hearing test may be necessary at a later stage if the serum drug level indicates a concern. Therefore, option C, obtaining a serum drug level, is the most appropriate action to take in this scenario.
A client is scheduled to undergo computerized tomography (CT) with contrast for evaluation of an abdominal mass. The nurse should tell the client that:
- A. The test may be painful
- B. The test takes 2 to 3 hours
- C. Food and fluids are not allowed for 4 hours after the test
- D. Dye is injected and may cause a warm flushing sensation
Correct Answer: D
Rationale: The correct answer is D. A contrast-aided CT scan involves the injection of dye to enhance the images obtained. The dye may cause a warm flushing sensation when injected, which is a common side effect. Choices A, B, and C are incorrect. CT with contrast is generally not a painful procedure, the duration of the test does not usually take 2 to 3 hours, and restrictions on food and fluids are typically before the test, not afterward.
A client with autosomal dominant polycystic kidney disease (ADPKD) asks, "Will my children develop this disease?" How should the nurse respond?
- A. No genetic link is known, so your children are not at increased risk.
- B. Your sons will develop this disease because it has a sex-linked gene.
- C. Only if both you and your spouse are carriers of this disease.
- D. Each of your children has a 50% risk of having ADPKD.
Correct Answer: D
Rationale: Children whose parent has the autosomal dominant form of PKD have a 50% chance of inheriting the gene that causes the disease. ADPKD is transmitted as an autosomal dominant trait and therefore is not gender-specific. Both parents do not need to have this disorder. Choice A is incorrect because ADPKD has a known genetic link and a definitive mode of inheritance. Choice B is incorrect as ADPKD is not sex-linked but autosomal dominant. Choice C is incorrect because ADPKD follows an autosomal dominant inheritance pattern and does not require both parents to be carriers for the child to inherit the disease.
The nurse is preparing to give a dose of a cephalosporin medication to a patient who has been receiving the antibiotic for 2 weeks. The nurse notes ulcers on the patient's tongue and buccal mucosa. Which action will the nurse take?
- A. Hold the drug and notify the provider.
- B. Obtain an order to culture the oral lesions.
- C. Gather emergency equipment to prepare for anaphylaxis.
- D. Report a possible superinfection side effect of the cephalosporin.
Correct Answer: D
Rationale: The nurse should report a possible superinfection side effect of the cephalosporin to the physician as the patient's symptoms may indicate a superinfection that requires treatment. Holding the drug is not necessary unless directed by the provider. Culturing the lesions is not indicated for this situation. There is no evidence to suggest impending anaphylaxis based on the patient's symptoms.