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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The nurse caring for a client receiving intravenous therapy monitors for which signs of infiltration of an intravenous (IV) infusion? Select all that apply.
- A. Slowing of the IV rate
- B. Tenderness at the insertion site
- C. Edema around the insertion site
- D. Skin tightness at the insertion site
- E. Warmth of skin at the insertion site
- F. Fluid leaking from the insertion site
Correct Answer: A,B,C,D,F
Rationale: Infiltration is the leakage of an IV solution into the extravascular tissue. Manifestations include slowing of the IV rate; burning, tenderness, or general discomfort at the insertion site; increasing edema in or around the catheter insertion site; complaints of skin tightness; blanching or coolness of the skin; and fluid leaking from the insertion site.
The nurse is assessing a pregnant client with a diagnosis of abruptio placentae. Which manifestations of this condition should the nurse expect to note? Select all that apply.
- A. Uterine irritability
- B. Uterine tenderness
- C. Painless vaginal bleeding
- D. Abdominal and low back pain
- E. Strong and frequent contractions
- F. Nonreassuring fetal heart rate patterns
Correct Answer: A,B,D,F
Rationale: Placental abruption, also referred to as abruptio placentae, is the separation of a normally implanted placenta before the fetus is born. It occurs when there is bleeding and formation of a hematoma on the maternal side of the placenta. Manifestations include uterine irritability with frequent low-intensity contractions, uterine tenderness that may be localized to the site of the abruption, aching and dull abdominal and low back pain, painful vaginal bleeding, and a high uterine resting tone identified by the use of an intrauterine pressure catheter. Additional signs include nonreassuring fetal heart rate patterns, signs of hypovolemic shock, and fetal death. Painless vaginal bleeding is a sign of placenta previa.
A client is admitted to the hospital with a diagnosis of acute bacterial pericarditis. Which nursing assessment findings are associated with this form of heart disease? Select all that apply.
- A. Fever
- B. Leukopenia
- C. Bradycardia
- D. Pericardial friction rub
- E. Decreased erythrocyte sedimentation rate
- F. Precordial chest pain that intensifies by the supine position
Correct Answer: A,D,F
Rationale: In acute bacterial pericarditis, the membranes surrounding the heart become inflamed and rub against each other, producing the classic pericardial friction rub. Fever typically occurs and is accompanied by leukocytosis and an elevated erythrocyte sedimentation rate. The client complains of severe precordial chest pain that intensifies when lying supine and decreases in a sitting position. The pain also intensifies when the client breathes deeply. Malaise, myalgia, and tachycardia are common.
The nurse is caring for a client with a diagnosis of pemphigus vulgaris. On assessment of the client, the nurse should look for which sign characteristic of this condition?
- A. Turner's sign
- B. Chvostek's sign
- C. Nikolsky's sign
- D. Trousseau's sign
Correct Answer: C
Rationale: A hallmark sign of pemphigus vulgaris is Nikolsky's sign, which occurs when the epidermis can be rubbed off by slight friction or injury. Other characteristics include flaccid bullae that rupture easily and emit a foul-smelling drainage, leaving crusted, denuded skin. The lesions are common on the face, back, chest, and umbilicus. Even slight pressure on an intact blister may cause spread to adjacent skin. Turner's sign refers to a grayish discoloration of the flanks and is seen in clients with acute pancreatitis. Chvostek's sign, seen in tetany, is a spasm of the facial muscles elicited by tapping the facial nerve in the region of the parotid gland. Trousseau's sign is a sign for tetany, in which carpal spasm can be elicited by compressing the upper arm with a blood pressure cuff inflated above the systolic pressure and causing ischemia to the nerves distally.
To monitor for a temporary but common postsurgical complication of a transsphenoidal resection of the pituitary gland, the nurse should regularly perform which assessment?
- A. Pulse rate
- B. Temperature
- C. Urine output
- D. Oxygen saturation
Correct Answer: C
Rationale: A common complication of surgery on the pituitary gland is temporary diabetes insipidus. This results from a deficiency in antidiuretic hormone (ADH) secretion as a result of surgical trauma. The nurse measures the client's urine output to determine whether this complication is occurring. Polyuria of 4 to 24 L per day is characteristic of this complication. Options 1, 2, and 4 are not specifically related to a common complication after this surgery.