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Which observation, if reported by a client, is most suggestive of an adverse reaction to gentamicin?
- A. A WBC of 8000
- B. Ringing in the ears
- C. Itching
- D. Nasal stuffiness
Correct Answer: B
Rationale: Gentamicin is ototoxic. Ringing in the ears suggests possible damage to the eighth cranial nerve, the auditory nerve. A WBC of 8000 is normal.
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A client with atrial fibrillation is receiving digoxin (Lanoxin). Which of these assessments is most important for the nurse to perform?
- A. Monitor blood pressure every 4 hours
- B. Measure apical pulse prior to administration
- C. Maintain accurate intake and output records
- D. Record an EKG strip after administration
Correct Answer: B
Rationale: Measure apical pulse prior to administration. Digitoxin decreases conduction velocity through the AV node and prolongs the refractory period. If the apical heart rate is less than 60 beats/minute, withhold the drug. The apical pulse should be taken with a stethoscope so that there will be no mistake about what the heart rate actually is.
The client's vital signs are T 99.2°F, AP 59, R 20, and BP 108/72. Which medication would the nurse question administering?
- A. Theo-Dur, a bronchodilator.
- B. Inderal, a beta blocker.
- C. Ampicillin, an antibiotic.
- D. Cardizem, a calcium channel blocker.
Correct Answer: B
Rationale: Inderal (propranolol) slows HR; an apical pulse of 59 warrants holding it, per guidelines, to avoid bradycardia. Other meds are unaffected by HR.
An adult received regular insulin at 7:00 A.M. At 10:00 A.M., she is irritable and sweaty, but her skin is cool. What is the most appropriate action for the nurse to take?
- A. Have her lie down for a rest
- B. Give her a cola drink
- C. Give ordered insulin
- D. Encourage exercise
Correct Answer: B
Rationale: Irritability, sweating, and cool skin suggest hypoglycemia. A cola drink provides quick-acting carbohydrates to raise blood sugar.
A 6-year-old child is seen in the emergency room after stepping on a rusty nail. He has received no immunizations. What should the nurse expect to give him immediately to prevent a tetanus infection?
- A. Tetanus toxoid
- B. DTaP
- C. Immune serum globulin
- D. Penicillin
Correct Answer: C
Rationale: Immune serum globulin provides immediate passive immunity against tetanus in an unimmunized child.
The nurse administers 18 units of Humulin N, an intermediate-acting insulin, at 1630. Which priority intervention should the nurse implement?
- A. Monitor the client's hemoglobin A1c.
- B. Make sure the client eats the evening meal.
- C. Check the a.c. blood glucometer reading.
- D. Ensure the client eats a snack.
Correct Answer: B
Rationale: Humulin N peaks in 4–12 hours; evening meal prevents hypoglycemia during peak action. A1c, a.c. checks, or snacks are less immediate.