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The nurse is caring for a client who is receiving IV gentamicin for a gram-negative infection. Which of the following findings would be of GREATest concern to the nurse?
- A. Creatinine 2.0 mg/dL.
- B. Heart rate of 80 bpm.
- C. Blood pressure of 120/80 mmHg.
- D. Temperature of 99.5°F (37.5°C).
Correct Answer: A
Rationale: A creatinine of 2.0 mg/dL indicates renal impairment, a serious complication of gentamicin due to nephrotoxicity, requiring immediate evaluation. Options B, C, and D are normal or less concerning: heart rate 80 bpm, blood pressure 120/80 mmHg, and temperature 99.5°F are stable.
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The preoperative client is from a different country and tells the nurse that his family will be coming for a prayer service. Eighteen persons arrive and start chanting in the client's semiprivate room. What is the best response for the nurse?
- A. Explain that visitors are limited to two per client
- B. Ask the client's roommate if he/she objects to so many persons in the room
- C. Ignore the large number of people and the chanting
- D. Arrange for the group to go to the conference room or the chapel
Correct Answer: D
Rationale: Arranging for a private space respects cultural practices while minimizing disruption to the roommate, balancing sensitivity and practicality.
While monitoring the urine specific gravity of a client with a head injury, the nurse notes that the client's specific gravity is 1.004 . The most likely explanation for this finding is:
- A. The client is adequately hydrated.
- B. The client is experiencing renal failure.
- C. The client has adequate ADH secretion.
- D. The client is experiencing diabetes insipidus.
Correct Answer: D
Rationale: A low specific gravity (1.004) suggests dilute urine, common in diabetes insipidus due to impaired ADH secretion, often seen in head injuries.
The nurse is teaching a client with a new diagnosis of chronic obstructive pulmonary disease (COPD) about tiotropium (Spiriva). Which of the following statements by the client indicates a need for further teaching?
- A. I should rinse my mouth after using this inhaler.
- B. I should use this inhaler once a day.
- C. I should report eye pain to my doctor.
- D. I should use this inhaler when I have trouble breathing.
Correct Answer: D
Rationale: Using tiotropium as a rescue inhaler is incorrect, as it is a long-acting maintenance medication for COPD, not for acute symptoms. Options A, B, and C are correct: rinsing prevents oral thrush, daily use is standard, and eye pain may indicate glaucoma.
A client has returned from having a transurethral prostatectomy. Which finding should be reported to the doctor immediately?
- A. An hourly urinary output of 40-50 mL
- B. Bright red urine with many clots
- C. Dark red urine with few clots
- D. Requests for pain med every 4 hours
Correct Answer: B
Rationale: Bright red urine with many clots indicates significant bleeding post-prostatectomy, requiring immediate reporting. Normal output is 40-50 mL/hour, dark red urine with few clots is expected, and pain med requests are routine.
Prior to suctioning a tracheotomy, the nurse should:
- A. Suction the oropharynx.
- B. Administer oxygen.
- C. Change the inner cannula.
- D. Raise the head of the bed.
Correct Answer: B
Rationale: Administering oxygen pre-suctioning prevents hypoxia, as suctioning can reduce oxygen levels. Oropharyngeal suctioning, cannula changes, or bed elevation are not primary pre-suction steps.