The nurse is preparing to administer intravenous gentamicin to an infant through an intermittent needle. The nurse notes that the infant has not had a wet diaper for several hours. The nurse will perform which action?
- A. Administer the medication and give the infant extra oral fluids.
- B. Contact the provider to request adding intravenous fluids when giving the medication.
- C. Give the medication and obtain a serum peak drug level 45 minutes after the dose.
- D. Hold the dose and contact the provider to request a serum trough drug level.
Correct Answer: D
Rationale: In this scenario, the infant not having a wet diaper for several hours indicates a potential decrease in urine output, which can be a sign of nephrotoxicity related to gentamicin. The correct action for the nurse is to hold the dose and contact the provider to request a serum trough drug level. This is important to monitor the drug levels and ensure that they are not reaching toxic levels. Administering the medication without addressing the decreased urine output could potentially lead to further nephrotoxicity. Contacting the provider to add intravenous fluids or obtaining a serum peak drug level are not the most appropriate actions in this situation as the priority is to assess for potential nephrotoxicity and ensure patient safety.
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The nurse is administering intravenous fluids to a dehydrated patient. On the second day of care, the patient's weight has increased by 2.25 pounds. The nurse would expect that the patient's fluid intake has
- A. equaled urine output.
- B. exceeded urine output by 1 L.
- C. exceeded urine output by 2.5 L.
- D. exceeded urine output by 3 L.
Correct Answer: B
Rationale: A weight gain of 1 kg, or approximately 2.2 to 2.5 lb, is generally equivalent to 1 liter (L) of fluid retained by the body. In this case, the patient's weight gain of 2.25 pounds suggests an excess fluid retention of approximately 1 liter, indicating that the patient's fluid intake has exceeded urine output by 1 liter. Choices C and D are incorrect as they overestimate the fluid excess based on the patient's weight gain. Choice A is incorrect as it implies an exact balance between fluid intake and urine output, which is not reflected in the given weight increase.
A patient is diagnosed with Mycoplasma pneumonia. Which antibiotic will the nurse expect the provider to order to treat this infection?
- A. Azithromycin (Zithromax)
- B. Clarithromycin (Biaxin)
- C. Erythromycin (E-Mycin)
- D. Fidaxomicin (Dificid)
Correct Answer: C
Rationale: Erythromycin is the drug of choice for treating Mycoplasma pneumonia. Mycoplasma pneumonia is typically sensitive to macrolide antibiotics, with erythromycin being one of the first-line agents. Azithromycin and clarithromycin are also effective in treating Mycoplasma pneumonia, but erythromycin is specifically mentioned as the drug of choice in this context. Fidaxomicin, on the other hand, is not indicated for the treatment of Mycoplasma pneumonia and is primarily used to treat Clostridium difficile infections.
A client is experiencing diarrhea. For which acid-base disorder should the nurse assess the client?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: A
Rationale: When a client experiences diarrhea, the loss of bicarbonate-rich fluids from the body leads to a decrease in the bicarbonate levels in the blood, resulting in metabolic acidosis. Metabolic alkalosis (choice B) is characterized by an increase in bicarbonate levels, which is not typically associated with diarrhea. Respiratory acidosis (choice C) is caused by retention of carbon dioxide, while respiratory alkalosis (choice D) results from excessive exhalation of carbon dioxide, neither of which are directly related to diarrhea. Therefore, the correct answer is metabolic acidosis (choice A) in the context of diarrhea.
A client is getting out of bed for the first time since surgery. The client complains of dizziness after the nurse raises the head of the bed. Which of the following actions should the nurse take first?
- A. Checking the client's blood pressure
- B. Checking the oxygen saturation level
- C. Having the client take some deep breaths
- D. Lowering the head of the bed slowly until the dizziness is relieved
Correct Answer: D
Rationale: When a client experiences dizziness after being positioned upright for the first time post-surgery, the initial action the nurse should take is to lower the head of the bed slowly until the dizziness subsides. This maneuver helps alleviate the dizziness by allowing the body to adapt gradually to the change in position. Subsequently, the nurse should assess the client's pulse and blood pressure. Checking the blood pressure is essential to evaluate the circulatory status and rule out orthostatic hypotension as a cause of dizziness. Checking the oxygen saturation level and having the client take deep breaths are not the priority in this scenario as the primary concern is addressing the circulatory issue causing dizziness, not a respiratory problem.
A client who underwent lobectomy 24 hours ago has not had any chest tube drainage for the past hour. What should the nurse do first?
- A. Contacts the physician
- B. Checks for kinks in the drainage system
- C. Checks the client's blood pressure and heart rate
- D. Connects a new drainage system to the client's chest tube
Correct Answer: B
Rationale: When a chest tube is not draining, the nurse's initial action should be to check for kinks or clots in the chest drainage system. This step helps to ensure the patency of the system and allows for proper drainage. Checking the client's blood pressure and heart rate is important but not the priority when addressing a lack of chest tube drainage. Contacting the physician is warranted if signs of respiratory distress or mediastinal shift are observed after ruling out kinks or clots. Connecting a new drainage system is done when the fluid chamber is full, following a specific procedure to maintain a closed system and prevent complications.