Nokea
A nurse is caring for a client who is receiving IV gentamicin. Which of the following actions should the nurse take?
- A. Monitor the client's hearing.
- B. Administer the medication over 15 min.
- C. Check the client's blood glucose levels.
- D. Instruct the client to increase fluid intake.
Correct Answer: A
Rationale: Gentamicin risks ototoxicity, so hearing monitoring is critical. It's infused slowly, glucose isn't affected, and fluid intake depends on condition.
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A nurse is caring for a client who is receiving continuous bladder irrigation following a TURP. Which of the following findings should the nurse report to the provider?
- A. The client reports bladder spasms.
- B. The irrigation fluid is slightly pink.
- C. The client's urine output is bright red with clots.
- D. The client's catheter is draining freely.
Correct Answer: C
Rationale: Bright red urine with clots indicates potential hemorrhage, requiring immediate reporting. Spasms and pink fluid are expected, and free drainage is normal.
A nurse is caring for a client who is receiving oxygen at 2 L/min via nasal cannula. Which of the following actions should the nurse take?
- A. Apply petroleum jelly to the client's nares.
- B. Secure the cannula tubing behind the client's ears.
- C. Change the nasal cannula every 24 hr.
- D. Ensure the oxygen tubing is free of kinks.
Correct Answer: D
Rationale: Kink-free tubing ensures proper oxygen delivery. Petroleum jelly risks aspiration, securing tubing varies, and cannula changes aren't daily.
A nurse is caring for a client who is receiving chemotherapy. Which of the following actions should the nurse take to prevent infection?
- A. Encourage the client to avoid fresh fruits and vegetables.
- B. Administer prophylactic antibiotics daily.
- C. Monitor the client's white blood cell count regularly.
- D. Instruct the client to avoid crowded places.
Correct Answer: C
Rationale: Monitoring WBC counts detects neutropenia early, guiding infection prevention. Fresh produce is safe if washed, antibiotics aren't routine, and avoiding crowds is secondary.
A nurse is caring for a client who is postoperative following a craniotomy. Which of the following findings should the nurse report to the provider?
- A. The client reports a headache.
- B. The client's pupils are unequal.
- C. The client's incision has minimal drainage.
- D. The client's blood pressure is 130/85 mm Hg.
Correct Answer: B
Rationale: Unequal pupils suggest increased intracranial pressure or neurological deterioration, requiring reporting. Headache, minimal drainage, and normal BP are less urgent.
A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse take if a transfusion reaction is suspected?
- A. Increase the infusion rate.
- B. Administer diphenhydramine.
- C. Stop the transfusion.
- D. Elevate the client's legs.
Correct Answer: C
Rationale: Stopping the transfusion prevents further reaction. Increasing the rate worsens it, diphenhydramine is secondary, and leg elevation is unrelated.