Nokea
The nurse should monitor for which potential complication in a client receiving IV vancomycin and gentamicin?
- A. Blood in nasogastric tube drainage
- B. Decrease in red blood cell count
- C. Increase in serum creatinine level
- D. Onset of muscle aches and cramping
Correct Answer: C
Rationale: Vancomycin and gentamicin are nephrotoxic, so monitoring for increased serum creatinine is essential to detect kidney injury. GI bleeding , anemia , and muscle cramps are less directly related.
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The most common complication following a myocardial infarction is:
- A. Hyperkalemia
- B. Cardiac dysrhythmia
- C. Acute respiratory distress
- D. Hypovolemic shock
Correct Answer: B
Rationale: Cardiac dysrhythmias are the most common complication post-myocardial infarction due to ischemic changes affecting the heart's electrical conduction.
The nurse is reviewing the medical record of a 4-year-old client with failure to thrive. Which of the following risk factors likely contribute to the client's condition? Select all that apply.
- A. Child is the youngest of four children in the home
- B. One parent is incarcerated for spousal abuse
- C. One parent was diagnosed with anorexia nervosa prior to having children
- D. One parent works a full-time job outside the home
- E. Parents are concerned about not having enough money to buy food
Correct Answer: B,C,E
Rationale: FTT risk factors include parental incarceration causing family stress, a history of anorexia nervosa affecting feeding practices, and food insecurity . Being the youngest or a working parent are not direct risks.
What socioeconomic indicators would the nurse identify as risk factors for a 2-month-old infant to develop failure to thrive (FTT)? Select all that apply.
- A. Both caregivers work outside the home
- B. Infant lives only with mother, who is currently unemployed
- C. Infant's primary caregiver has cognitive disabilities
- D. Parents are socially and emotionally isolated
- E. Parents live together but are not married
Correct Answer: B,C,D
Rationale: Risk factors for FTT include unemployment limiting resources, caregiver cognitive disabilities impairing care, and social/emotional isolation reducing support. Working parents and unmarried status are not direct risks.
A client who has congestive heart failure is being admitted. How should the nurse position this client?
- A. Supine
- B. Sims'
- C. Semi-sitting
- D. Side-lying
Correct Answer: C
Rationale: Semi-sitting (Fowler's position) reduces cardiac workload and improves breathing in congestive heart failure by decreasing venous return.
The practical nurse is assisting the registered nurse in creating a teaching plan for the parents of a child diagnosed with pediculosis capitis. Which instructions should be included in the teaching plan? Select all that apply.
- A. It is not necessary to treat other children in the household
- B. Soak the child's comb and hair accessories in boiling water for 10 minutes
- C. The family pet will need treatment with a pediculicide
- D. Use a nit comb daily for 2 weeks after pediculicide treatment
- E. Vacuum the furniture, carpets, and mattresses every few days
Correct Answer: B,D,E
Rationale: For pediculosis capitis (head lice), soaking combs in boiling water , using a nit comb daily , and vacuuming furniture prevent reinfestation. Other children should be checked and treated if infested (A is incorrect), and pets do not require treatment as lice are human-specific.