Nokea
A nurse is caring for a client who is receiving IV gentamicin. Which of the following findings should the nurse report to the provider?
- A. The client reports mild nausea.
- B. The client's urine output is 30 mL/hr.
- C. The client's hearing has decreased.
- D. The client's blood pressure is 120/78 mm Hg.
Correct Answer: C
Rationale: Decreased hearing suggests ototoxicity, a serious gentamicin side effect requiring reporting. Nausea, low urine output, and normal BP are less urgent.
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A nurse is caring for a client who is receiving IV fluids with potassium chloride. Which of the following actions should the nurse take?
- A. Monitor the client's cardiac rhythm.
- B. Administer the IV fluids through a large-gauge needle.
- C. Check the client's magnesium levels every 8 hr.
- D. Instruct the client to reduce sodium intake.
Correct Answer: A
Rationale: Potassium chloride can cause arrhythmias, so cardiac monitoring is essential. Needle size varies, magnesium isn't routinely checked, and sodium restriction isn't specific.
A nurse is reinforcing teaching with a client who has a new prescription for fluoxetine. Which of the following statements should the nurse include?
- A. You should take this medication at bedtime.
- B. You might experience weight loss while taking this medication.
- C. You need to avoid tyramine-rich foods while taking this medication.
- D. You can expect symptom improvement within 24 hours.
Correct Answer: A
Rationale: Fluoxetine is often taken at bedtime to minimize daytime side effects like agitation. Weight changes vary, tyramine isn't a concern, and effects take weeks.
A nurse is caring for a client who is postoperative following a total knee arthroplasty. Which of the following findings should the nurse report to the provider?
- A. The client reports mild pain at the surgical site.
- B. The client's temperature is 38.3°C (100.9°F).
- C. The client's knee is slightly swollen.
- D. The client can flex the knee 90 degrees.
Correct Answer: B
Rationale: A temperature of 38.3°C suggests infection, requiring reporting. Mild pain, slight swelling, and good flexion are expected post-arthroplasty.
A nurse is caring for a client who is postoperative following a craniotomy. Which of the following actions should the nurse take?
- A. Position the client flat in bed.
- B. Monitor the client's neurological status every 2 hr.
- C. Encourage the client to cough vigorously.
- D. Administer a stool softener as needed.
Correct Answer: B
Rationale: Frequent neurological checks detect complications like increased intracranial pressure early. Flat positioning risks pressure, vigorous coughing is avoided, and stool softeners prevent straining.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take?
- A. Check the client's blood glucose levels regularly.
- B. Administer TPN through a peripheral IV line.
- C. Change the TPN bag every 48 hr.
- D. Monitor the client's blood pressure every 4 hr.
Correct Answer: A
Rationale: TPN's high glucose content requires regular blood glucose monitoring to prevent hyperglycemia. It's given centrally, bags change every 24 hours, and blood pressure isn't specific.