Nokea
A patient is taking Streptomycin. Which finding below requires the nurse to notify the physician?
- A. Patient reports a change in vision.
- B. Patient reports a metallic taste in the mouth.
- C. The patient has ringing in their ears.
- D. The patient has a persistent dry cough.
Correct Answer: C
Rationale: Streptomycin can cause ototoxicity, leading to symptoms like ringing in the ears (tinnitus). This requires immediate physician notification to prevent further hearing damage.
You may also like to solve these questions
When performing the client's tracheostomy care, which nursing action is correct?
- A. Cut a gauze square to fit around the client's stoma.
- B. Secure the ties at the back of the client's neck.
- C. Attach new ties before removing old ones.
- D. Replace the cannula after changing the ties.
Correct Answer: C
Rationale: Attaching new ties before removing old ones ensures the tracheostomy tube remains secure, preventing accidental dislodgement.
When the nurse obtains the nasal swab, which action is most accurate?
- A. The nurse dons sterile gloves before obtaining the specimen.
- B. The swab is placed in the anterior portion of the nare and swept superiorly.
- C. The client is asked to blow the nose before the specimen is collected.
- D. The nurse uses separate applicators for each nare.
Correct Answer: D
Rationale: Using separate applicators for each nare prevents cross-contamination and ensures an accurate sample for MRSA screening.
Which option below is considered a positive Homan's Sign for the assessment of a deep vein thrombosis (DVT)?
- A. The patient reports pain when the foot is manually dorsiflexed.
- B. The patient reports pain when the foot is manually plantarflexed.
- C. The patient experiences pain when the leg is extended.
- D. the patient experiences pain when the leg is flexed.
Correct Answer: A
Rationale: Homan's Sign is NOT reliable because of false positives, but know for exams how to elicit a response. It done by manually (forced) dorsiflexing the patient's foot (bending it up towards the shin) and if it causes the patient pain it considered a positive Homan's Sign. However, the MD must further investigate if the patient has a DVT.
The client diagnosed with a pulmonary embolus is in the intensive care department. Which assessment data warrant immediate intervention from the nurse?
- A. The client's ABGs are pH 7.36, Pao2 95, Paco2 38, Hco3 24.
- B. The client's telemetry exhibits occasional premature ventricular contractions (PVCs).
- C. The client's pulse oximeter reading is 90%.
- D. The client's urinary output for the 12-hour shift is 800 mL.
Correct Answer: C
Rationale: SpO2 90% (C) indicates hypoxia in PE, requiring immediate oxygen adjustment. Normal ABGs (A), occasional PVCs (B), and urine output (D) are less urgent.
A client comes to the clinic with a bloody nose. Which instruction is most appropriate?
- A. Sit up with your head tilted forward. Grasp the soft part of your nose firmly between your thumb and forefinger.'
- B. Lay down and tilt your head backward. Grasp the end of your nose between your fingers.'
- C. Sit up and lean backwards. Put pressure on the side of your nose with your hand.'
- D. Lie down with your head lower than your feet. Grasp as much of your nose as possible between your fingers.'
Correct Answer: A
Rationale: Sitting with the head tilted forward and grasping the soft part of the nose prevents aspiration of blood and effectively stops bleeding.