Nokea
When caring for the client who is receiving an aminoglycoside antibiotic, the nurse should monitor which of the following laboratory values?
- A. Serum sodium.
- B. Serum potassium.
- C. Serum creatinine.
- D. Serum calcium.
Correct Answer: C
Rationale: Aminoglycosides are nephrotoxic; monitoring serum creatinine assesses kidney function. Sodium, potassium, and calcium are not primarily affected by aminoglycosides.
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The nurse is to administer Polycillin (ampicillin) 500 mg orally to a client with a ruptured appendix. The nurse checks the capsule in the client's medication box which is located inside of the client's room. The dosage of the medication is not labeled, but the nurse recognizes the color and shape of the capsule. The nurse should next:
- A. Administer the medication to maintain blood levels of the drug.
- B. Ask another registered nurse to verify that the capsule is ampicillin.
- C. Contact the pharmacy to bring a properly labeled medication.
- D. Adjust the unit manager to report the problem.
Correct Answer: C
Rationale: Contacting the pharmacy to bring a properly labeled medication ensures safe administration, as recognizing the capsule's color and shape is insufficient for verification. Administering without confirmation or relying on another nurse risks error, and reporting to the manager delays care. CN: Safety and infection control; CL: Synthesize
A client with multiple sclerosis (MS) lives with her daughter and 3-year-old granddaughter. The daughter asks the nurse what she can do at home to help her mother. Which of the following measures would be most beneficial?
- A. Psychotherapy.
- B. Regular exercise.
- C. Day care for the granddaughter.
- D. Weekly visits by another person with MS.
Correct Answer: B
Rationale: Regular exercise is most beneficial, as it maintains mobility, strength, and overall health in MS. Psychotherapy, daycare, or peer visits may help but are less directly impactful.
A 42-year-old husband and father of a 7-year-old girl and a 10-year-old boy is concerned about what he should tell his children regarding his wife's impending death from aggressive breast cancer. The nurse should:
- A. Refer the family to pastoral care services.
- B. Encourage the husband to come to terms with his own grief first.
- C. Suggest that the children be told nothing until after death occurs.
- D. Begin education about strategies for communication with his children.
Correct Answer: D
Rationale: Educating the husband on communication strategies helps him prepare his children for their mother's death, fostering understanding and emotional support.
On admission to same-day surgery, the nurse reviews the chart to verify the client's identification documentation. Which of the following is most important?
- A. Admitting record.
- B. Addressograph labels.
- C. Identification bracelet.
- D. Location of family.
Correct Answer: C
Rationale: The identification bracelet is the most reliable method to verify client identity, ensuring safety and preventing errors in same-day surgery.
Blood pressure in the systemic circulation is highest in the:
- A. Arterioles
- B. Capillaries
- C. Aorta
- D. Venules
Correct Answer: C
Rationale: Blood pressure is highest in the aorta, where blood is ejected directly from the left ventricle during systole, generating peak pressure (systolic pressure). As blood flows through arterioles, capillaries, and venules, pressure progressively decreases due to resistance and vessel compliance. This makes the aorta the correct answer.