Nokea
Which of the following is an adverse effect of vancomycin (Vancocin) and needs to be reported promptly?
- A. Vertigo.
- B. Tinnitus.
- C. Muscle stiffness.
- D. Ataxia.
Correct Answer: B
Rationale: Tinnitus is a sign of ototoxicity, a serious adverse effect of vancomycin that requires prompt reporting to prevent permanent hearing damage.
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Which client should the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. A client who needs teaching regarding the use of an incentive spirometer
- B. A client who needs to have a urine specimen collected for a clean catch urine
- C. A client who needs reinforcement of a dressing covering an abdominal incision
- D. A client who needs assessment of a newly identified area of pressure over the right hip
Correct Answer: B
Rationale: The UAP can assist with specimen collection such as a clean catch urine because he or she is trained in this skill. Skills requiring nursing intervention such as dressing changes, teaching, and assessment cannot be delegated to unlicensed personnel.
A client with pneumonia is receiving oxygen therapy. The nurse notes cyanosis and a respiratory rate of 32 breaths/min. What should the nurse do first?
- A. Increase the oxygen flow rate.
- B. Notify the physician.
- C. Encourage coughing and deep breathing.
- D. Reposition the client.
Correct Answer: B
Rationale: Cyanosis and tachypnea indicate worsening hypoxia, requiring immediate physician notification to adjust treatment.
A 32-year-old woman recently diagnosed with Hodgkin's disease is admitted to the hospital outpatient clinic for staging by undergoing a bone marrow aspiration and biopsy. To obtain more information about the client's nutrition status the nurse should review the results of which of the following tests?
- A. Red blood cell count.
- B. Direct and indirect bilirubin levels.
- C. Reticulocyte count.
- D. Albumin level.
Correct Answer: D
Rationale: Albumin levels reflect nutritional status, as low levels indicate protein malnutrition, common in cancer patients. The other tests assess hematologic or liver function.
A nurse is assessing a newborn 12 hours after birth. Which of the following findings should be reported to the physician immediately?
- A. Milia on the nose
- B. Mongolian spots on the back
- C. Caput succedaneum
- D. Jaundice on the face
Correct Answer: D
Rationale: Jaundice within 24 hours of birth is pathological and requires immediate evaluation. Milia, Mongolian spots, and caput succedaneum are normal findings.
The nurse is caring for a client who is having an acute asthma attack. The nurse should notify the physician of which of the following?
- A. Loud wheezing.
- B. Tenacious, thick sputum.
- C. Decreased breath sounds.
- D. Persistent cough.
Correct Answer: C
Rationale: Decreased breath sounds indicate severe airway obstruction in an asthma attack, requiring immediate physician notification.