Nokea
Which of the following serum laboratory values would the nurse monitor during gentamicin therapy?
- A. Creatinine
- B. Sodium
- C. Calcium
- D. Potassium
Correct Answer: A
Rationale: A common side effect of gentamicin is nephrotoxicity. The serum laboratory test that best reflects kidney function is serum creatinine.
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A client with a history of chronic lymphocytic leukemia is admitted with complaints of lymphadenopathy. The nurse should give priority to:
- A. Monitoring for infection
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering chemotherapy
Correct Answer: A
Rationale: Lymphadenopathy in chronic lymphocytic leukemia increases infection risk, so monitoring for infection is the priority.
A client has just received an epidural block. She is laboring on her right side. The nurse notes that her blood pressure has dropped from 132/68 to 78/42 mm Hg. The nurse's first action would be to:
- A. Call the physician immediately and give dopamine IM
- B. Turn her on her left side and recheck her blood pressure in 5 minutes
- C. Administer oxytocin (Pitocin) immediately and increase the rate of IV fluids
- D. Increase the rate of IV fluids and start O2 by mask
Correct Answer: D
Rationale: Nursing measures to support fetal oxygenation and promote maternal blood pressure would precede calling the physician. Systolic pressures below 100 mm Hg or a reduction in the systolic pressure of >30% necessitate treatment. Assessing the blood pressure in 5 minutes may allow for further fetal and/or maternal compromise. Turning the client on her left side will promote uteroplacental perfusion and is appropriate. Oxytocin (Pitocin) increases the strength of uterine contractions and may cause maternal hypotension; thus it is an inappropriate drug for use in this clinical situation. IV fluids would be increased to expand the circulating blood volume and promote increased blood pressure. Turning the mother to her left lateral side promotes uteroplacental perfusion. IV fluids are administered to increase the circulating blood volume, and O2 is administered to promote fetal oxygenation and decrease the nausea accompanying the hypotension.
The nurse explains perineal hygiene self-care postpartum to the client. She should be instructed to:
- A. Wear gloves for the procedure
- B. Place and adjust the pad from back to front
- C. Cleanse and wipe the perineum from front to back
- D. Protect the outer surface of the pad from contamination
Correct Answer: C
Rationale: (Tom) Perineal hygiene is a clean procedure and does not require the client to wear gloves. A care provider should wear gloves to adhere to universal precautions. The pad should be applied from front to back to prevent contamination of the birth canal or urinary tract from rectal bacteria. Wiping from front to back and discarding the wipe prevents contamination of the urinary tract and birth canal from rectal bacteria. The inner surface of the pad should not be touched to maintain asepsis.
Before administering intravenous chemotherapy to the patient being treated, the nurse should:
- A. Administer a bolus of IV fluid
- B. Administer pain medication
- C. Administer an antiemetic
- D. Allow the patient a chance to eat
Correct Answer: C
Rationale: Chemotherapy often causes nausea and vomiting, so administering an antiemetic prophylactically is standard to improve patient comfort. Fluid boluses, pain medication, or eating are not routine pre-chemotherapy steps unless specified.
The nurse is preparing to administer a dose of enoxaparin (Lovenox) to a client. Which injection site is most appropriate?
- A. Deltoid muscle
- B. Ventrogluteal muscle
- C. Anterolateral thigh
- D. Abdomen, 2 inches from the umbilicus
Correct Answer: D
Rationale: Enoxaparin, a low-molecular-weight heparin, is administered subcutaneously in the abdomen, 2 inches from the umbilicus, to ensure consistent absorption and minimize bruising. Muscle injections are inappropriate.