Nokea
The nurse is preparing to administer the fourth dose of vancomycin IVPB to a client with infective endocarditis. Which intervention should the nurse anticipate?
- A. Starting a new IV line before the administration
- B. Administering an antiemetic PRN prior to the infusion
- C. Administering medication via an infusion pump over at least 30 minutes
- D. Obtaining a serum trough level 15-30 minutes before the administration of vancomycin
Correct Answer: D
Rationale: Vancomycin requires therapeutic drug monitoring to ensure efficacy and prevent toxicity. Obtaining a serum trough level 15-30 minutes before the fourth dose (D) is standard to guide dosing adjustments. A new IV line (A) is unnecessary unless the current line is compromised. Antiemetics (B) are not routinely needed. Infusion over 60 minutes (C) is typical to prevent red man syndrome, not 30 minutes.
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The nurse is talking with a client with macular degeneration. Which of the following statements by the client would be consistent with the condition?
- A. I have been seeing small flashes of light in one eye.
- B. I noticed that my peripheral vision is becoming worse.
- C. I see a blurry spot in the middle of the page when I read.
- D. I cannot see the newspaper unless I hold it away from me.
Correct Answer: C
Rationale: Macular degeneration affects central vision, causing a blurry or dark spot in the visual field, as described in (C), due to damage to the macula. Flashes of light (A) suggest retinal issues, peripheral vision loss (B) is typical of glaucoma, and difficulty reading up close (D) relates to presbyopia.
An 8-year-old hospitalized due to a bowel obstruction is to be discharged home with a temporary colostomy. The parents’ primary language is Vietnamese, and their English proficiency is very limited. What is the best approach for the nurse to use when reinforcing instructions to the parents on how to care for the child at home?
- A. Demonstrate the procedure using simple English phrases
- B. Give the parents written instructions with picture illustrations
- C. Tell the parents to have a friend or relative come in to translate
- D. Use an interpreter via the telephone interpretation service
Correct Answer: D
Rationale: A professional interpreter (D) ensures accurate communication, critical for colostomy care. Simple English (A) risks misunderstanding, pictures (B) are insufficient alone, and informal translators (C) may lack medical accuracy.
A male client is admitted for evaluation of a sudden hearing loss. No physical cause can be found for his sudden deafness; however, a friend reveals that the client's fiancée recently canceled their engagement, saying that she needed more time to think about the marriage. The client's deafness is an example of:
- A. Conversion reaction
- B. Hypochondriasis
- C. Reaction formation
- D. Histrionic personality disorder
Correct Answer: A
Rationale: Sudden deafness after emotional stress, without physical cause, indicates a conversion reaction, where psychological distress manifests physically.
A client in labor with a history of a previous cesarean birth has chosen to attempt a vaginal birth. During labor, which finding would be most concerning to the nurse?
- A. Cessation of contractions and maternal tachycardia
- B. Fetal tachycardia with moderate variability
- C. Increased anxiety and discomfort with contractions
- D. Painful, strong contractions every 3-4 minutes
Correct Answer: A
Rationale: Cessation of contractions with maternal tachycardia (A) suggests uterine rupture, a life-threatening emergency in VBAC due to scar dehiscence. Fetal tachycardia (B) is concerning but less specific, anxiety (C) is expected, and regular contractions (D) are normal.
While teaching the family of a child who will take phenytoin (Dilantin) regularly for seizure control, it is most important for the nurse to teach them about which of the following actions?
- A. Maintain good oral hygiene and dental care
- B. Omit medication if the child is seizure free
- C. Administer acetaminophen to promote sleep
- D. Serve a diet that is high in iron
Correct Answer: A
Rationale: Swollen and tender gums occur often with use of phenytoin. Good oral hygiene and regular visits to the dentist should be emphasized.