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 client is receiving a continuous heparin drip, 20,000 units/500 mL D5W, at 23 mL/min. How many units of heparin is the client receiving an hour?
Correct Answer: 55200
Rationale: Concentration: 20,000 units / 500 mL = 40 units/mL. Rate: 23 mL/min x 60 min/hr = 1,380 mL/hr. Dose: 1,380 mL/hr x 40 units/mL = 55,200 units/hr.
The nurse is to administer an IM injection to a 6-month-old child. What is the most appropriate site to use?
- A. Vastus lateralis
- B. Dorsal gluteal
- C. Ventral gluteal
- D. Iliac crest
Correct Answer: A
Rationale: Infants and small children do not have enough muscle in the gluteal area to use that site. The vastus lateralis is the appropriate site. The iliac crest is a site used for SC injections, not IM.
The nurse in the physician's office is instructing an adult about taking penicillin V potassium (Pen-Vee-K) qid. When should the nurse tell him to take the medicine?
- A. With meals and at bedtime
- B. Once a day at 10:00 a.m.
- C. On an empty stomach at six-hour intervals
- D. With orange juice at four-hour intervals
Correct Answer: C
Rationale: Penicillin V potassium should be taken on an empty stomach at six-hour intervals to optimize absorption.
A client has been receiving dexamethasone (Decadron) for control of cerebral edema. Which of the following assessments would indicate that the treatment is effective?
- A. A positive Babinski's reflex
- B. Increased response to motor stimuli
- C. A widening pulse pressure
- D. Temperature of 37 degrees Celsius
Correct Answer: B
Rationale: Decadron is a corticosteroid that acts on the cell membrane to decrease inflammatory responses as well as stabilize the blood-brain barrier. Once Decadron reaches a therapeutic level, there should be a decrease in symptomatology with improvement in motor skills.
An adult client has pulmonary tuberculosis. He is receiving isoniazid (INH) 300 mg PO, ethambutol 1 g PO daily, and streptomycin 1 g IM three times a week. When he comes in for a checkup, he tells the nurse that he hates getting shots and his ears ring most of the time. What is the best interpretation for the nurse to make regarding the client's complaints?
- A. He may be receiving too much ethambutol.
- B. He should be evaluated for adverse reaction to streptomycin.
- C. Tuberculosis may have spread to the brain.
- D. He is experiencing a reaction commonly seen when INH and streptomycin are given at the same time.
Correct Answer: B
Rationale: Streptomycin is ototoxic, and ringing in the ears (tinnitus) is a sign of potential eighth cranial nerve damage, requiring evaluation.