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The nurse is completing an ongoing assessment of a client receiving erythromycin. The nurse would notify the primary health care provider immediately if assessment reveals which of the following? Select all that apply.
- A. Significant drop in blood pressure
- B. Increase in heart rate
- C. Decrease in temperature
- D. Increase in respiratory rate
Correct Answer: A, B, D, E
Rationale: During ongoing assessment of a client receiving erythromycin, the nurse should notify the primary health care provider immediately if the client has a significant drop in blood pressure, increase in heart rate, increase in respiratory rate, or sudden increase in temperature.
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A group of nursing students are reviewing information about clindamycin (Cleocin). The students demonstrate understanding of this drug when they identify that it should be used with caution in clients with which of the following? Select all that apply.
- A. Seizure disorder
- B. GI disorders
- C. Myasthenia gravis
- D. Diabetes
Correct Answer: B, C, E
Rationale: Clindamycin, a lincosamide, should be used cautiously in clients with a history of GI disorders, renal disease, liver impairment, or myasthenia gravis.
A client has been receiving an aminoglycoside for several weeks and comes to the clinic complaining of ringing in his ears and some dizziness. The nurse suspects ototoxicity. When developing this client's plan of care, which nursing diagnosis would be the priority?
- A. Impaired Comfort
- B. Altered Thought Process
- C. Diarrhea
- D. Risk for Injury
Correct Answer: D
Rationale: The development of ototoxicity would lead the nurse to identify a nursing diagnosis of Risk for Injury related to the effects of ototoxicity. Although the client's ringing in the ears could cause discomfort, the priority nursing diagnosis would be Risk for Injury. There is no evidence of impaired comfort, altered thought process or diarrhea.
A group of nursing students are reviewing information about aminoglycosides. The students demonstrate understanding when they identify which of the following as an example? Select all that apply.
- A. Amikacin (Amikin)
- B. Amoxicillin (Amoxil)
- C. Kanamycin (Kantrex)
- D. None of the above
Correct Answer: A
Rationale: The aminoglycosides include amikacin, gentamicin, kanamycin, neomycin, streptomycin, and tobramycin. Amoxicillin is an aminopenicillin. Vancomycin is a miscellaneous agent that disrupts the bacterial cell wall. Azithromycin is classified as a macrolide.
A patient is ordered to receive neomycin as part of the treatment plan for hepatic coma. Which of the following would be most important for the nurse to assess before administering this drug? Select all that apply.
- A. Ability to swallow
- B. Level of consciousness
- C. Baseline vital signs
- D. Pulmonary function
Correct Answer: A, B
Rationale: During the early stages of hepatic coma, various changes in the level of consciousness may be seen. At times, the patient may appear lethargic and respond poorly to commands. Because of these changes in the level of consciousness, the patient may have difficulty swallowing, and a danger of aspiration is present. If the patient appears to have difficulty taking an oral drug, the nurse should withhold the drug and contact the primary health care provider. Baseline vital signs are important but are not the priority when the patient has hepatic coma. The drug does not affect the patient's respiratory function. There is no infection; therefore, there is no need for culture and sensitivity testing.
A patient is to receive tetracycline therapy at home. After teaching the patient about foods to avoid when taking the drug, the nurse determines that the teaching was successful when the patient states he will avoid which of the following? Select all that apply.
- A. Yogurt
- B. Cheese
- C. Calcium-fortified cereals
- D. Citrus fruits
Correct Answer: A, B, C
Rationale: The patient should avoid dairy products including yogurt, cheese, milk, cream, ice cream, ice milk, or frozen custard before or after taking tetracycline. Citrus fruits and green leafy vegetables should not be avoided.