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A nurse is caring for a client receiving gentamicin. For which of the following should the nurse monitor the client?
- A. Tinnitus
- B. Tachycardia
- C. Polyuria
- D. Photophobia
Correct Answer: A
Rationale: The correct answer is A: Tinnitus. The nurse should monitor the client for tinnitus because gentamicin can cause ototoxicity, leading to hearing loss and tinnitus. Tachycardia (B), polyuria (C), and photophobia (D) are not commonly associated with gentamicin use. Tachycardia may be a sign of other issues, polyuria could indicate kidney problems, and photophobia is sensitivity to light, which is not a typical side effect of gentamicin. Therefore, the nurse should focus on monitoring for tinnitus as a potential adverse effect of gentamicin therapy.
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A nurse is collecting data from a client who has been taking diazepam several times per day but recently ran out of the medication. Which of the following findings should the nurse recognize as a manifestation of withdrawal from diazepam?
- A. Tremors
- B. Anorexia
- C. Drowsiness
- D. Hypotension
Correct Answer: A
Rationale: The correct answer is A: Tremors. Diazepam is a benzodiazepine used to treat anxiety and withdrawal symptoms. Withdrawal from diazepam can lead to physical symptoms such as tremors due to the sudden decrease in the drug's effects on the central nervous system. Tremors are a common manifestation of benzodiazepine withdrawal. Anorexia (choice B) is not typically associated with diazepam withdrawal. Drowsiness (choice C) is more likely a side effect of diazepam itself, not withdrawal. Hypotension (choice D) is not a common withdrawal symptom of diazepam.
A nurse is reinforcing teaching with a client who has a new prescription for sustained-release verapamil. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will crush the tablet to make it easier to swallow.
- B. I will increase my daily intake of fiber and fluid.
- C. I will follow up with monthly laboratory tests to check for anemia.
- D. I will sit upright for 30 minutes after taking the medication.
Correct Answer: B
Rationale: The correct answer is B: I will increase my daily intake of fiber and fluid. This response indicates understanding because sustained-release verapamil can cause constipation as a side effect. Increasing fiber and fluid intake can help prevent constipation and promote proper bowel function. Crushing sustained-release tablets can alter the drug's intended release mechanism, leading to potential overdose or underdose. Following up with monthly laboratory tests for anemia is not directly related to verapamil therapy. Sitting upright after taking the medication is more relevant for bisphosphonates to prevent esophageal irritation.
A nurse is evaluating the laboratory results of four clients. The nurse should report which of the following laboratory results to the provider?
- A. A client who has a prescription for heparin and an aPTT of 90 seconds (30-40 seconds).
- B. A client who has a prescription for warfarin and an INR of 2.0 (0.8 to 1.1).
- C. A client who has a prescription for heparin and an aPTT of 65 seconds (30-40 seconds).
- D. A client who has a prescription for warfarin and an INR of 3.0 (0.8 to 1.1).
Correct Answer: A
Rationale: The correct answer is A. A client who has a prescription for heparin and an aPTT of 90 seconds (30-40 seconds) should be reported to the provider because the aPTT result is significantly above the therapeutic range, indicating a potential risk of bleeding due to excessive anticoagulation. Heparin therapy requires close monitoring of aPTT levels to ensure the medication's efficacy and safety. Reporting this result promptly to the provider allows for timely adjustment of the heparin dosage to prevent complications.
Choices B, C, and D are incorrect because they fall within or close to the desired therapeutic ranges for the respective medications. Therefore, they do not require immediate reporting to the provider as they suggest appropriate anticoagulation levels.
A nurse is caring for a client who started taking amitriptyline 6 days ago. The client reports that the medication is not helping. Which of the following responses should the nurse make?
- A. I will ask your provider to increase the dose of the medication.
- B. You will need to take this medication on an empty stomach for it to be more effective.
- C. You will need to wait a couple of weeks to feel the therapeutic effect of the medication.
- D. I will inform your provider so they can prescribe a different medication.
Correct Answer: C
Rationale: The correct response is C: "You will need to wait a couple of weeks to feel the therapeutic effect of the medication." Amitriptyline, a tricyclic antidepressant, typically takes 2-4 weeks to start showing its full therapeutic effects. It is important for the nurse to educate the client about the delayed onset of action to manage expectations. Option A is incorrect because increasing the dose prematurely can lead to adverse effects. Option B is incorrect as taking it on an empty stomach is not necessary for its efficacy. Option D is incorrect as switching medications without giving the current one a fair trial may not be appropriate.
A nurse is preparing to administer 0800 medications to a client. The medication administration record (MAR) states 'phenobarbital' and the medication the pharmacy supplied is pentobarbital. Which of the following actions should the nurse take?
- A. Check the client's MAR to see what the client received the day before
- B. Ask the client what medication she took yesterday.
- C. Ask the client if she has any allergies.
- D. Check the prescription in the client's medical record.
Correct Answer: D
Rationale: The correct answer is D: Check the prescription in the client's medical record. This is the appropriate action for the nurse to take because it ensures that the medication being administered matches the prescription ordered by the healthcare provider. By verifying the prescription in the client's medical record, the nurse can confirm if pentobarbital is indeed the correct medication prescribed for the client. Checking the MAR alone may not provide the necessary information about the prescribed medication. Asking the client about previous medications or allergies (choices A, B, C) may not be reliable sources of information regarding the specific prescription. Therefore, option D is the most appropriate and logical course of action in this situation.