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The nurse is caring for a client with a history of epilepsy who is receiving carbamazepine (Tegretol) 200 mg PO bid. Which of the following laboratory results should the nurse report immediately?
- A. White blood cell count of 3,000/mm^3.
- B. Sodium 140 mEq/L.
- C. Potassium 4.0 mEq/L.
- D. Hemoglobin 13 g/dL.
Correct Answer: A
Rationale: A white blood cell count of 3,000/mm^3 indicates leukopenia, a serious carbamazepine side effect. Options B, C, and D are normal.
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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.
The nurse is caring for a client with a new colostomy. Which of the following client statements indicates a need for further teaching?
- A. I should change the pouch when it’s about one-third full.
- B. I should empty the pouch every morning.
- C. I should eat a high-fiber diet to prevent constipation.
- D. I should check the skin around the stoma for irritation.
Correct Answer: B
Rationale: Emptying the pouch every morning is a rigid schedule that does not account for individual bowel patterns; it should be emptied when one-third to one-half full. Options A, C, and D are correct: changing when one-third full prevents leaks, high-fiber diets promote regularity, and skin checks prevent breakdown.
A patient with type I diabetes mellitus (IDDM) asks the nurse why the doctor ordered human insulin instead of beef or pork insulin. Which of the following responses by the nurse is BEST?
- A. Human insulin is less likely to cause you to have a localized allergic reaction to the injection.'
- B. Human insulin will cause you to experience fewer problems with hypoglycemia or hyperglycemia.'
- C. Human insulin prevents the development of long-term damage to the eyes and kidneys.'
- D. Human insulin does not cause the formation of antibodies because the protein structure is identical to your own.'
Correct Answer: D
Rationale: protein molecules are identical with human insulin
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.
The nurse is assigned to care for a client who has a leaking intracranial aneurysm. To minimize the risk of rebleeding, the nurse should plan to
- A. restrict visitors to immediate family
- B. avoid arousal of the client except for family visits
- C. keep client's hips flexed at no less than 90 degrees
- D. apply a warming blanket for temperatures of 98 degrees Fahrenheit or less
Correct Answer: A
Rationale: restrict visitors to immediate family. Maintaining a quiet environment will assist in minimizing cerebral rebleeding. When family visit, the client should not be disturbed. If the client is awake, topics of a general nature are better choices for discussion than topics that result in emotional or physiological stimulation.