Nokea
Which of the following medications puts the client at risk for developing hearing loss?
- A. Rifampin
- B. Ciprofloxacin
- C. Penicillin G
- D. Gentamicin
Correct Answer: D
Rationale: The correct answer is D: Gentamicin. Gentamicin is an aminoglycoside antibiotic known to cause ototoxicity, leading to hearing loss. It can damage the hair cells in the inner ear, affecting hearing. Rifampin (A), Ciprofloxacin (B), and Penicillin G (C) are not associated with ototoxicity. Gentamicin should be used cautiously to prevent hearing loss.
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The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client. Nursing Action: Document the blood product transfusion in the client's medical record.
- A. Indicated
- B. Not indicated
Correct Answer: A
Rationale: The correct answer is A: Indicated. Documenting the blood product transfusion in the client's medical record is crucial for legal, ethical, and continuity of care reasons. Documentation ensures that all relevant information about the transfusion is recorded accurately, including the type of blood product, volume infused, patient's vital signs, any adverse reactions, and the healthcare provider's orders. This documentation serves as a permanent record of the procedure, aiding in monitoring the patient's response to the transfusion and facilitating communication among healthcare team members. Failure to document the blood transfusion can lead to serious consequences, such as improper monitoring, increased risk of errors, and compromised patient safety. Therefore, documenting the blood product transfusion in the client's medical record is a vital and necessary nursing action. Other choices are incorrect as they do not address the importance of documentation in ensuring safe and effective patient care.
Complete the following sentence by using the lists of options. Upon analyzing the assessment findings, the nurse identifies that the client is at risk for _______ due to _______.
- A. concurrent medication use
- B. recent illness
- C. activity level
Correct Answer: A
Rationale: The correct answer is A: concurrent medication use. This is because identifying a client at risk for a condition due to concurrent medication use is crucial in nursing assessment. Medications can interact with each other, leading to adverse effects or reduced efficacy. Recent illness (B) and activity level (C) are important factors but do not directly relate to the risk due to medication use. The other choices (D, E, F, G) are irrelevant and do not address the potential risks associated with medication interactions. Thus, A is the most appropriate choice for identifying a client's risk based on assessment findings related to medication use.
A nurse is assessing a client 1 hr after administering morphine for pain. The nurse should identify which of the following findings as the best indication that the morphine has been effective?
- A. The client's vital signs are within normal limits.
- B. The client has not requested additional medication.
- C. The client is resting comfortably with eyes closed.
- D. The client rates pain as 3 on a scale from 0 to 10.
Correct Answer: D
Rationale: Correct Answer: D. The client rates pain as 3 on a scale from 0 to 10.
Rationale: Pain assessment is subjective. The client's self-report of pain is the most reliable indicator of pain relief efficacy. A pain rating of 3 indicates that the pain has decreased from the initial level, suggesting that the morphine has been effective in managing the pain.
Summary of Other Choices:
A: The client's vital signs being within normal limits may not directly correlate with pain relief. Vital signs can be influenced by various factors other than pain relief.
B: The client not requesting additional medication does not necessarily indicate effective pain management as some individuals may hesitate to ask for more medication.
C: The client resting comfortably with eyes closed may indicate relaxation but does not specifically confirm pain relief.
E, F, G: No additional choices provided.
Which of the following actions is the priority for the nurse to take after inadvertently administering 160 mg of valsartan PO to a client who was scheduled to receive 80 mg?
- A. Evaluate the client for orthostatic hypotension
- B. Monitor the client's urine output
- C. Obtain the client's laboratory results
- D. Check the client for nasal congestion
Correct Answer: A
Rationale: The correct answer is A: Evaluate the client for orthostatic hypotension. After administering a double dose of Valsartan, the priority is to assess the client for potential adverse effects such as a sudden drop in blood pressure, which can lead to orthostatic hypotension. This is crucial to prevent any harm to the client. Monitoring urine output (B) may be important but is not the immediate priority. Obtaining laboratory results (C) would not provide immediate information on the client's current condition. Checking for nasal congestion (D) is irrelevant to the situation.
For which of the following client outcomes should the nurse administer chlordiazepoxide to a client experiencing acute alcohol withdrawal?
- A. Minimize diaphoresis
- B. Maintain abstinence
- C. Lessen craving
- D. Prevent delirium tremens
Correct Answer: D
Rationale: The correct answer is D: Prevent delirium tremens. Chlordiazepoxide is a benzodiazepine used to manage acute alcohol withdrawal symptoms, including preventing delirium tremens, a severe and potentially life-threatening complication. It helps to stabilize the client's central nervous system by reducing the risk of seizures and severe agitation associated with delirium tremens. Choices A, B, and C are incorrect as chlordiazepoxide's primary role in alcohol withdrawal is not to minimize diaphoresis, maintain abstinence, or lessen craving, but rather to manage the more serious symptoms of withdrawal like delirium tremens.