Nokea
The nurse is reviewing laboratory test results for an 80-year-old client who has a methicillin-resistant Staphylococcus aureus infection and is receiving vancomycin. Which of the following test results would require immediate follow-up?
- A. elevated BUN
- B. decreased serum iron level
- C. decreased serum triglyceride level
- D. elevated capillary blood glucose level
Correct Answer: A
Rationale: Elevated BUN (A) may indicate nephrotoxicity, a serious side effect of vancomycin requiring immediate follow-up. Decreased iron (B) or triglycerides (C) are not directly related to vancomycin toxicity. Elevated glucose (D) may need monitoring but is less urgent.
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The nurse is caring for a client with leukemia who is receiving the drug doxorubicin (Adriamycin). Which, if occurred, would be reported to the charge nurse immediately due to the toxic effects of this drug?
- A. Rales and distended neck veins
- B. Red discoloration of the urine and an output of 75 ml the previous hour
- C. Nausea and vomiting
- D. Elevated BUN and dry flaky skin
Correct Answer: A
Rationale: This drug can cause cardiotoxicity exhibited by changes in the ECG and congestive heart failure. Rales and distended neck veins are clinical manifestations of congestive heart failure, so answer A is correct. A reddish discoloration to the urine is a harmless side effect, so answer B is incorrect. An elevated BUN and dry, flaky skin are not specific to this drug, so answers C and D are incorrect.
The nurse is providing care to a client with posttraumatic stress disorder following a terrorist attack at the client's place of worship. The client says, 'I'm just so worried all the time. I will never be safe again!' What is the priority nursing action?
- A. Acknowledge the client's feelings
- B. Assess the client's support system
- C. Encourage the client to talk about the trauma
- D. Offer the client a PRN sleep medication
Correct Answer: A
Rationale: Acknowledging feelings (A) builds trust and validates the client's experience, making it the priority. Assessing support (B), discussing trauma (C), or offering medication (D) are secondary.
A client just diagnosed with methicillin-resistant Staphylococcus aureus septic arthritis is receiving the first dose of IV vancomycin. Which finding is most concerning to the nurse?
- A. Diffuse muscle pain
- B. Flushing and pruritus
- C. Low blood pressure
- D. Wheezing and hives
Correct Answer: D
Rationale: Wheezing and hives (D) indicate a possible anaphylactic reaction, the most concerning finding. Muscle pain (A), flushing/pruritus (B), and low blood pressure (C) are less immediately life-threatening.
The clinic nurse evaluates a client who was prescribed lithium therapy a month ago for bipolar disorder. Which client statement would cause the most concern?
- A. I've felt the need for an afternoon nap most days this week.'
- B. I've gained 3 lb (1.36 kg) since I began taking this medication.'
- C. I've had the stomach flu for the past couple of days.'
- D. My mouth seems to be drier than usual lately.'
Correct Answer: C
Rationale: Stomach flu (C) can cause dehydration, increasing lithium toxicity risk, requiring immediate concern. Naps (A), weight gain (B), and dry mouth (D) are less urgent side effects.
The nurse is caring for a hospitalized client diagnosed with thyrotoxicosis (thyroid storm). Which action is most appropriate to assign to unlicensed assistive personnel?
- A. Call the family to give an update on new aspects of the client's condition
- B. Lower the temperature in the room to make the environment cooler
- C. Reinforce teaching about signs and symptoms of hyperthyroidism
- D. Take vital signs and place a warming blanket on the client
Correct Answer: B
Rationale: Lowering room temperature (B) is within UAP scope and helps manage hyperthermia. Calling family (A), teaching (C), and applying a warming blanket (D) are inappropriate or require nursing judgment.