Nokea
A female client has been hospitalized for several months following major abdominal surgery for a ruptured colon. A colostomy was created, and the large abdominal wound was left open and allowed to heal through granulation. She is receiving gentamicin IV for treatment of wound infection. Knowing this drug is ototoxic, the nurse would implement which of the following measures?
- A. Instruct the client to report any signs of tinnitus, dizziness or difficulty hearing.
- B. Advise the client to discontinue the drug at the first sign of dizziness.
- C. Order audiometric testing in order to determine if hearing loss is caused by an ototoxic drug or other cause.
- D. Instruct the client in Valsalva's maneuver to equalize middle ear pressure and to prevent hearing loss.
Correct Answer: A
Rationale: The first nursing measure is to instruct the client in which drug side effects to report. Discontinuing the drug is not an independent nursing intervention and may compromise client care. Audiometric testing will detect hearing loss, but it does not indicate a potential cause. Equalizing middle ear pressure will not prevent hearing loss.
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The client is admitted with a diagnosis of molar pregnancy. Which symptom is most likely to be present?
- A. Severe nausea and vomiting
- B. Uterine size smaller than expected
- C. Fetal heart tones at 12 weeks
- D. All of the above
Correct Answer: A
Rationale: Molar pregnancy (hydatidiform mole) often causes severe nausea and vomiting due to high levels of human chorionic gonadotropin (hCG). The uterus is typically larger than expected and fetal heart tones are absent as there is no viable fetus.
An 8-year-old boy has been diagnosed with hemophilia. Which of the following diagnostic blood studies is characteristically abnormal in this disorder?
- A. Partial thromboplastin time
- B. Platelet count
- C. Complete blood count
- D. Bleeding time
Correct Answer: A
Rationale: Partial thromboplastic time measures activity of thromboplastin, which depends on the intrinsic clotting factors deficient in children who are hemophiliacs. Platelet counts are normal in hemophilia. Hemophilia does not affect the complete blood count. Bleeding times are normal in hemophiliacs. They measure the time interval for the bleeding from small superficial wounds to cease.
A client with a history of a burn injury is receiving Collagenase (Santyl). The nurse should:
- A. Apply the ointment to healthy skin
- B. Cover the wound with a dry dressing
- C. Clean the wound before application
- D. Expose the wound to air after application
Correct Answer: C
Rationale: Collagenase is applied to debride burn wounds, requiring a clean wound bed for effectiveness. It’s applied only to the wound, covered with a moist dressing, and not exposed to air.
The registered nurse is making shift assignments. Which client should be assigned to the licensed practical nurse (LPN)?
- A. A client who is a diabetic with a foot ulcer
- B. A client with a deep vein thrombosis receiving intravenous heparin
- C. A client being weaned from a tracheostomy
- D. A post-operative cholecystectomy with a T-tube
Correct Answer: A
Rationale: A diabetic with a foot ulcer is stable and suitable for an LPN, who can perform wound care and monitoring. Heparin infusion (B), tracheostomy weaning (C), and T-tube management (D) require RN-level skills due to complexity and risk.
The following nursing diagnosis is written for a comatose client with cirrhosis of the liver and secondary splenomegaly--High risk for injury: Increased susceptibility to bleeding related to:
- A. Increased absorption of vitamin K
- B. Thrombocytopenia due to hypersplenism
- C. Diminished function of the Kupffer cells
- D. Increased synthesis of the clotting factors
Correct Answer: B
Rationale: There is a decreased absorption of vitamin K with cirrhosis of the liver. This decrease impairs blood coagulation and the formation of prothrombin. Thrombocytopenia, an increased destruction of platelets, occurs secondary to hypersplenism. A diminished function of the Kupffer cells occurs with cirrhosis of the liver, causing the client to become more susceptible to infections. A decrease in the synthesis of fibrinogen and clotting factors VII, IX, and X occurs with cirrhosis of the liver and increases the susceptibility to bleeding.