Nokea
The nurse is caring for a client who is receiving tobramycin sulfate intravenously every 8 hours. Which result should indicate to the nurse that the client is experiencing an adverse effect of the medication?
- A. A total bilirubin of 0.5 mg/dL (8.5 mcmol/L)
- B. An erythrocyte sedimentation rate of 15 mm/hour
- C. A blood urea nitrogen (BUN) of 30 mg/dL (10.8 mmol/L)
- D. A white blood cell count (WBC) of 6000 mm³ (6 × 10â¹/L)
Correct Answer: C
Rationale: Tobramycin sulfate is an aminoglycoside antibiotic. Adverse effects or toxic effects of tobramycin sulfate include nephrotoxicity as evidenced by an increased BUN and serum creatinine; irreversible ototoxicity as evidenced by tinnitus, dizziness, ringing or roaring in the ears, and reduced hearing; and neurotoxicity as evidenced by headaches, dizziness, lethargy, tremors, and visual disturbances. The normal BUN ranges from 10 to 20 mg/dL (3.6 to 7.1 mmol/L), depending on the laboratory. The normal total bilirubin level ranges from 0.3 to 1.0 mg/dL (5.1 to 17 mcmol/L). The normal sedimentation rate for a male is ≤15 mm/hr and for a female is ≤20 mm/hr. A normal WBC count is 5000 to 10,000 mm³ (5 to 10 × 10â¹/L).
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A client is experiencing pulmonary edema as an exacerbation of chronic left-sided heart failure. The nurse should assess the client for what manifestation?
- A. Weight loss
- B. Bilateral crackles
- C. Distended neck veins
- D. Peripheral pitting edema
Correct Answer: B
Rationale: The client with pulmonary edema presents primarily with symptoms that are respiratory in nature because the blood flow is stagnant in the lungs, which lie behind the left side of the heart from a circulatory standpoint. The client would experience weight gain from fluid retention, not weight loss. Distended neck veins and peripheral pitting edema are classic signs of right-sided heart failure.
A 2-year-old toddler has just returned from surgery where a hip spica cast was applied. Which nursing action will best maintain the child's skin integrity?
- A. Changing the toddler's diapers every 2 hours.
- B. Keeping the toddler's genital area open to the air.
- C. Implementing a 3-hour turning schedule for the toddler.
- D. Assessing the toddler's perineal area for redness regularly.
Correct Answer: A
Rationale: The spica cast is often needed to treat developmental hip dysplasia (DDH) or after hip/pelvis surgery. The cast encases the child's trunk and one or both legs while leaving access to the genital. Considering the age of the child, diapers will be in use and will need to be changed at least every 2 hours during the day and 3 to 4 hours during the night to help minimize the effect of urine and feces on the child's diaper area. Exposing the genital and perineal area to the air is an intervention that is implemented to assist in healing damaged skin tissue. Turning the child regularly is appropriate care but has no impact on the major issue of incontinence. Assessment of the skin is necessary but identifies skin breakdown once it has begun.
The nurse is developing a care plan for an older client being admitted to a long-term care facility. Which information should the nurse use to plan interventions for this client? Select all that apply.
- A. Older clients tend to be incontinent.
- B. Older clients are at risk for dehydration.
- C. Depression is a normal part of the aging process.
- D. Age-related skin changes require special monitoring.
- E. Older clients are at risk for complications of immobility.
- F. Confusion and cognitive changes are common findings in the older population.
Correct Answer: B,D,E
Rationale: Older clients are at risk for dehydration and complications related to immobility. Another normal physiological change that occurs during the aging process is loss of skin integrity. Incontinence, depression, confusion, and cognitive changes are not normal parts of the aging process.
The nurse reviews the client's most recent blood gas results that include a pH of 7.43, PCO2 of 31 mm Hg, and HCO3 of 21 mEq/L. Based on these results, the nurse determines that which acid-base imbalance is present?
- A. Compensated metabolic acidosis
- B. Compensated respiratory alkalosis
- C. Uncompensated respiratory acidosis
- D. Uncompensated metabolic alkalosis
Correct Answer: B
Rationale: The normal pH is 7.35 to 7.45, the normal PCO2 is 35 to 45 mm Hg, and the normal HCO3 is 22 to 27 mEq/L. The pH is elevated in alkalosis and low in acidosis. In a respiratory condition, the pH and the PCO2 move in opposite directions; that is, the pH rises and the PCO2 drops (alkalosis) or vice versa (acidosis). In a metabolic condition, the pH and the bicarbonate move in the same direction; if the pH is low, the bicarbonate level will be low also. In this client, the pH is at the high end of normal, indicating compensation and alkalosis. The PCO2 is low, indicating a respiratory condition (opposite direction of the pH).
The nurse is performing an assessment on a postterm infant. Which physical characteristic should the nurse expect to observe in this infant?
- A. Peeling of the skin
- B. Smooth soles without creases
- C. Lanugo covering the entire body
- D. Vernix that covers the body in a thick layer
Correct Answer: A
Rationale: The postterm infant (born after the 42nd week of gestation) exhibits dry, peeling, cracked, almost leather-like skin over the body, which is called desquamation. The preterm infant (born between 24 and 37 weeks of gestation) exhibits smooth soles without creases, lanugo covering the entire body, and thick vernix covering the body.