Nokea
A healthcare professional is caring for a client receiving gentamicin therapy. Which of the following client assessments is a priority for the healthcare professional to monitor for an adverse effect of this medication?
- A. Urinary output
- B. Serum glucose
- C. Respiratory rate
- D. Hearing acuity
Correct Answer: D
Rationale: The correct answer is D: Hearing acuity. Gentamicin is known to be ototoxic, which means it can cause damage to the auditory system leading to hearing loss. Monitoring hearing acuity is crucial to detect early signs of hearing impairment. Monitoring urinary output (choice A) is important for assessing kidney function but is not directly related to gentamicin's adverse effects. Monitoring serum glucose (choice B) and respiratory rate (choice C) are not specifically associated with gentamicin therapy.
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A nurse is caring for a client receiving IV vancomycin. The nurse notes flushing of the client's neck and chest. Which of the following actions should the nurse take?
- A. Stop the infusion
- B. Document the findings as a harmless reaction
- C. Slow the infusion rate
- D. Administer diphenhydramine
Correct Answer: C
Rationale: The correct action for the nurse to take when a client receiving IV vancomycin shows flushing of the neck and chest is to slow the infusion rate. Flushing is a common sign of Red Man Syndrome, which is associated with rapid infusions of vancomycin. Slowing down the infusion rate can help prevent further flushing and the development of Red Man Syndrome. Stopping the infusion (Choice A) may be too drastic if the symptoms are mild and can be managed by slowing the rate. Documenting the findings as a harmless reaction (Choice B) is incorrect because flushing should be addressed promptly to prevent complications. Administering diphenhydramine (Choice D) is not the initial or best intervention for flushing associated with vancomycin; slowing the infusion rate is the priority.
A nurse is caring for a client who has been prescribed amoxicillin. Which of the following client history findings requires the nurse to clarify the medication prescription?
- A. Hypertension
- B. Peptic ulcer disease
- C. Asthma
- D. Gastroesophageal reflux disease
Correct Answer: C
Rationale: The correct answer is C. Clients with a history of asthma should avoid amoxicillin due to potential hypersensitivity reactions. Amoxicillin can trigger asthma exacerbations in some individuals. Hypertension (choice A), peptic ulcer disease (choice B), and gastroesophageal reflux disease (choice D) are not contraindications for amoxicillin use, so they do not require the nurse to clarify the medication prescription in this case.
A nurse is providing client education regarding lithium therapy. Which of the following instructions should the nurse include?
- A. Take with food to decrease nausea
- B. Avoid excessive intake of caffeinated beverages
- C. Monitor for signs of dehydration
- D. Restrict salt intake to prevent water retention
Correct Answer: B
Rationale: The correct answer is B. The nurse should instruct the client to avoid excessive intake of caffeinated beverages as they can interfere with lithium levels. Option A is incorrect as lithium is usually recommended to be taken on an empty stomach. Option C is not directly related to lithium therapy. Option D is not a typical instruction for lithium therapy.
A nurse is preparing to administer an intramuscular injection to an adult client. At what angle should the nurse administer the medication using the ventrogluteal site?
- A. a 45-degree angle
- B. a 60-degree angle
- C. a 75-degree angle
- D. a 90-degree angle
Correct Answer: D
Rationale: Intramuscular injections in the ventrogluteal site should be administered at a 90-degree angle. This angle ensures that the medication reaches the muscle tissue effectively. Angles less than 90 degrees can cause subcutaneous injection instead of intramuscular, leading to slower absorption of the medication. Angles greater than 90 degrees risk hitting bone or nerves, causing unnecessary pain or injury. Therefore, the correct angle for administering intramuscular injections in the ventrogluteal site is 90 degrees.
A nurse is caring for a client newly prescribed doxazosin mesylate. Which of the following instructions should the nurse include in client education regarding taking the first dose of this medication?
- A. Change positions slowly and lie down if dizziness occurs
- B. There is no need to avoid normal activities
- C. Avoid dairy products while taking this medication
- D. Do not eat green leafy vegetables
Correct Answer: A
Rationale: Corrected Rationale: First-dose orthostatic hypotension can occur with doxazosin. The nurse should advise the client to change positions slowly and lie down if dizziness occurs. Choice B is incorrect because it does not address the potential side effect of dizziness. Choice C and D are also incorrect as there is no specific dietary restriction related to doxazosin mesylate.