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A nurse is caring for a client who is receiving IV vancomycin. Which of the following actions should the nurse take?
- A. Infuse the medication over 30 min.
- B. Monitor the client for tinnitus.
- C. Administer the medication with an antihistamine.
- D. Check the client's blood pressure every 4 hr.
Correct Answer: B
Rationale: Vancomycin can cause ototoxicity, so monitoring for tinnitus is essential. It's infused over 60-90 minutes, antihistamines aren't needed, and blood pressure checks aren't specific to vancomycin.
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A nurse is caring for a client who is postoperative following a mastectomy. Which of the following actions should the nurse take to promote arm mobility?
- A. Encourage the client to perform deep breathing exercises.
- B. Instruct the client to avoid using the affected arm for 6 weeks.
- C. Teach the client to perform range-of-motion exercises daily.
- D. Apply a compression bandage to the affected arm.
Correct Answer: C
Rationale: Daily range-of-motion exercises prevent stiffness and promote mobility. Breathing exercises, arm avoidance, or compression don't target mobility.
A nurse is caring for a client who is receiving IV fluids with potassium chloride. Which of the following findings should the nurse report to the provider?
- A. The client reports mild discomfort at the IV site.
- B. The client's heart rate is irregular.
- C. The client's urine output is 50 mL/hr.
- D. The client's blood pressure is 118/76 mm Hg.
Correct Answer: B
Rationale: An irregular heart rate suggests hyperkalemia or arrhythmia, requiring reporting. Mild discomfort, normal urine output, and stable BP are less concerning.
A nurse is reinforcing teaching with a client who has a new prescription for losartan. Which of the following statements should the nurse include?
- A. You should take this medication with a high-potassium meal.
- B. You might experience dizziness while taking this medication.
- C. You need to limit your exercise while taking this medication.
- D. You can take this medication at any time of day.
Correct Answer: B
Rationale: Losartan can cause dizziness due to blood pressure lowering, a key safety concern. Potassium meals, exercise limits, or flexible timing aren't primary considerations.
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 reinforcing teaching with a client who has a new prescription for doxycycline. Which of the following statements should the nurse include?
- A. You should take this medication on an empty stomach.
- B. You might experience sensitivity to sunlight.
- C. You need to refrigerate this medication.
- D. You can take this medication with an antacid.
Correct Answer: B
Rationale: Doxycycline increases photosensitivity, requiring sun protection. It's taken with food to avoid upset, doesn't need refrigeration, and antacids reduce absorption.