Nokea
The client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) is receiving the aminoglycoside antibiotic vancomycin. Peak and trough levels are ordered for the dose the nurse is administering. Which priority intervention should the nurse implement?
- A. Ask the client if he has had any diarrhea.
- B. Monitor the aminoglycoside peak level.
- C. Determine if the trough level has been drawn.
- D. Check the client's culture and sensitivity report.
Correct Answer: C
Rationale: Trough levels must be drawn before the next vancomycin dose to ensure therapeutic levels and avoid toxicity; this is the priority. Diarrhea, peak levels, or culture reports are secondary.
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The female nurse realizes she did not administer a medication on time to the client diagnosed with a myocardial infarction. Which action should the nurse implement?
- A. Administer the medication and take no further action.
- B. Notify the director of nurses of the medication error.
- C. Complete a medication error report form.
- D. Report the error to the Peer Review Committee.
Correct Answer: C
Rationale: A medication error requires completing an error report per facility policy to ensure tracking and quality improvement, especially for MI patients.
The elderly male client is admitted for acute severe diverticulitis. He has been taking Xanax, a benzodiazepine, for nervousness three (3) to four (4) times a day prn for six (6) years. Which intervention should the nurse implement first?
- A. Prepare to administer an intravenous antianxiety medication.
- B. Notify the HCP to obtain an order for the client's Xanax prn.
- C. Explain Xanax causes addiction and he should quit taking it.
- D. Assess for signs/symptoms of medication withdrawal.
Correct Answer: D
Rationale: Long-term Xanax use risks dependence; assessing withdrawal (e.g., agitation, seizures) is the priority during acute illness to guide safe management.
The nurse is administering carbidopa/levodopa (Sinemet) to the client. Which assessment should the nurse perform to determine if the medication is effective?
- A. Assess the client's muscle strength.
- B. Assess for cogwheel movements.
- C. Assess the carbidopa serum level.
- D. Assess the client's blood pressure.
Correct Answer: B
Rationale: Carbidopa/levodopa reduces Parkinson’s symptoms like cogwheel rigidity; decreased cogwheel movements indicate effectiveness. Strength, levels, or BP are less specific.
An adult client is receiving lithium 600 mg PO tid for the treatment of bipolar disorder. The client should be taught that it is important to have adequate amounts of which substance?
- A. Potassium
- B. Sodium
- C. Calcium
- D. Magnesium
Correct Answer: B
Rationale: Adequate sodium intake is crucial with lithium to prevent toxicity, as low sodium levels increase lithium retention.
A toddler who has swallowed several adult aspirin is admitted to the emergency room. When admitted, the child is breathing but is difficult to arouse. What is the immediate priority of care?
- A. Administration of syrup of ipecac
- B. Cardiopulmonary resuscitation
- C. Ventilatory support
- D. Gastric lavage
Correct Answer: D
Rationale: Gastric lavage is the priority to remove aspirin from the stomach, preventing further absorption, given the child is breathing but unresponsive.