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The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood pressure of 130/80 mmHg.
- B. Heart rate of 88 bpm.
- C. Redness at the IV site.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: Redness at the IV site suggests phlebitis or infiltration, which can lead to tissue damage or reduced vancomycin delivery, requiring immediate action. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 88 bpm, and urine output 50 mL/hour indicate stability.
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While assessing a client in an outpatient facility with a panic disorder, the nurse completes a thorough health history and physical exam. Which finding is most significant for this client?
- A. Compulsive behavior
- B. Sense of impending doom
- C. Fear of flying
- D. Predictable episodes
Correct Answer: B
Rationale: Sense of impending doom. The feeling of overwhelming and uncontrollable doom is characteristic of a panic attack.
The nurse is screening an eight-month-old girl in a well-baby clinic. The nurse would be MOST concerned if the infant's mother made which of the following statements?
- A. My daughter has almost doubled her birth weight.
- B. When I walk in the room my child smiles at me.
- C. When she is around her grandpa, my child cries.
- D. My daughter can't quite say Mama yet.
Correct Answer: A
Rationale: An eight-month-old should have doubled birth weight by 5–6 months; 'almost doubled' suggests growth delay, requiring evaluation. Options B, C, and D are normal behaviors.
The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood pressure of 130/80 mmHg.
- B. Heart rate of 90 bpm.
- C. Facial flushing and itching.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: Facial flushing and itching suggest red man syndrome, a serious reaction to vancomycin, requiring immediate slowing of the infusion or antihistamine administration. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 90 bpm, and urine output 50 mL/hour are stable.
The LPN/LVN is caring for an adult who has pneumonia. The nurse should instruct the nursing assistant to report which information immediately?
- A. Restlessness
- B. Pink-colored skin
- C. Nonproductive cough
- D. Dry mouth
Correct Answer: A
Rationale: Restlessness may indicate hypoxia in pneumonia, a critical symptom requiring immediate reporting to assess oxygenation status.
A client two days after surgery, a shiny, pink, open area is noted with the underlying bowel visible.
When the nurse assesses the incision of a client two days after surgery, a shiny, pink, open area is noted with the underlying bowel visible. Which of these actions should the nurse take FIRST?
- A. Cover the open area with sterile gauze soaked in normal saline.
- B. Reapply a sterile dressing after cleaning the incision with peroxide.
- C. Pack the opened area with sterile 3/4-inch gauze soaked in normal saline.
- D. Apply Neosporin ointment and cover the incision with Tegaderm dressing.
Correct Answer: A
Rationale: Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? (1) correct-evisceration is treated immediately by application of sterile gauze soaked in sterile normal saline, followed by notification of physician (2) not correct response to this complication (3) not correct response to this complication (4) not correct response to this complication