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In caring for a client receiving the aminoglycoside antibiotic gentamicin, what diagnostic test should the nurse prioritize monitoring?
- A. Urinalysis
- B. Serum creatinine
- C. Serum osmolarity
- D. Liver enzymes
Correct Answer: B
Rationale: The correct answer is B: Serum creatinine. Aminoglycosides, such as gentamicin, are known to cause nephrotoxicity, which can lead to kidney damage. Monitoring serum creatinine levels is crucial in assessing renal function and detecting any potential kidney problems early. Choices A, C, and D are incorrect because urinalysis primarily assesses urine composition, serum osmolarity measures the concentration of solutes in the blood, and liver enzymes are not directly impacted by aminoglycoside antibiotics like gentamicin.
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The nurse reviews the laboratory findings of a client with an open fracture of the tibia. The white blood cell (WBC) count and erythrocyte sedimentation rate (ESR) are elevated. Before reporting this information to the healthcare provider, what assessment should the nurse obtain?
- A. Appearance of wound
- B. Pain level
- C. Presence of fever
- D. Mobility status
Correct Answer: A
Rationale: The correct answer is A: Appearance of wound. Elevated WBC and ESR levels suggest a possible infection in the client with an open fracture. Assessing the wound's appearance is crucial to evaluate for signs of infection, such as redness, warmth, swelling, or drainage. By assessing the wound first, the nurse can provide important information to the healthcare provider regarding the potential infection, which may require immediate intervention. Choices B, C, and D are important assessments in caring for a client with an open fracture; however, in this scenario, the priority is to assess the wound for signs of infection due to the elevated WBC and ESR levels.
In assessing a client 48 hours following a fracture, the nurse observes ecchymosis at the fracture site and recognizes that hematoma formation at the bone fragment site has occurred. What action should the nurse implement?
- A. Document the extent of the bruising in the medical record.
- B. Apply a cold compress to the area.
- C. Elevate the affected limb.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: After observing ecchymosis at the fracture site, indicating hematoma formation, the nurse's priority is to document the extent of the bruising in the medical record. This documentation helps track the client's condition, aids in treatment planning, and serves as a baseline for monitoring changes. Applying a cold compress (choice B) may be contraindicated due to the risk of vasoconstriction and potential tissue damage. Elevating the affected limb (choice C) can be beneficial for reducing swelling in some cases, but documenting the bruising is the immediate concern. Notifying the healthcare provider (choice D) is not necessary at this stage unless there are other concerning symptoms or complications beyond the hematoma formation.
The nurse and an unlicensed assistive personnel (UAP) are providing care for a client with a nasogastric tube (NGT) when the client begins to vomit. How should the nurse manage this situation?
- A. Direct the UAP to measure the emesis while the nurse irrigates the NGT
- B. Stop the NGT feed and notify the healthcare provider
- C. Increase the NGT suction pressure
- D. Elevate the head of the bed
Correct Answer: A
Rationale: During vomiting in a client with an NGT, it is essential for the nurse to direct the UAP to measure the emesis to monitor the output. This helps in assessing the client's condition and response to treatment. Meanwhile, irrigating the NGT can be beneficial to relieve any obstruction that might be contributing to the vomiting. Stopping the NGT feed and notifying the healthcare provider (choice B) is important but not the immediate action needed. Increasing the NGT suction pressure (choice C) is unnecessary and can lead to complications. Elevating the head of the bed (choice D) is a general intervention to prevent aspiration but may not address the immediate issue of managing the vomiting episode and potential tube obstruction.
A newly graduated female staff nurse approaches the nurse manager and requests reassignment to another client because a male client is asking her for a date and making suggestive comments. Which response is best for the nurse manager to provide?
- A. I have to call the supervisor to get someone else to transfer to this unit to care for him.
- B. I know you are a good nurse and can handle this client in a professional manner.
- C. I'll talk to the client about his sexual harassment and insist that he stop immediately.
- D. I'll change your assignment, but let's talk about how a nurse should respond to this kind of client.
Correct Answer: D
Rationale: The best response for the nurse manager is option D. Changing the assignment while providing guidance on professional boundaries and how to handle such situations is essential. Option A is not appropriate as it does not address the issue of the client's behavior. Option B, although supportive, does not offer a solution to the problem at hand. Option C is not the best approach as directly confronting the client about sexual harassment may escalate the situation further.
The nurse is assessing a client with chronic heart failure who is receiving furosemide (Lasix). Which assessment finding is most concerning?
- A. Heart rate of 60 beats per minute
- B. Blood pressure of 110/70 mmHg
- C. Elevated liver enzymes
- D. Elevated blood glucose level
Correct Answer: C
Rationale: Elevated liver enzymes are most concerning in a client with chronic heart failure as they may indicate liver congestion or worsening heart failure, requiring immediate intervention. Elevated liver enzymes can be a sign of hepatotoxicity or liver damage, which could be a result of furosemide (Lasix) use. Monitoring liver function is crucial in patients taking furosemide due to the risk of hepatotoxicity. A heart rate of 60 beats per minute and a blood pressure of 110/70 mmHg are within normal ranges for a client with chronic heart failure. An elevated blood glucose level may be expected due to the effects of furosemide but is not as immediately concerning as elevated liver enzymes.