Nokea
Which symptom is considered an adverse reaction to Kantrex (kanamycin)?
- A. Diminished hearing
- B. Hypotension
- C. Hepatomegaly
- D. Petechiae
Correct Answer: A
Rationale: Kanamycin, an aminoglycoside, is ototoxic, and diminished hearing is a known adverse reaction requiring monitoring.
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The nurse is caring for an elderly client after hip replacement surgery. The client is distressed because he has not had a bowel movement in 3 days. Which action by the nurse would be most appropriate?
- A. Administer the prescribed as-needed milk of magnesia
- B. Ask dietary services to add more fruits and vegetables to the client’s tray
- C. Notify the registered nurse
- D. Perform a focused abdominal assessment
Correct Answer: D
Rationale: A focused abdominal assessment determines the cause of constipation (e.g., impaction, obstruction) before interventions like laxatives, dietary changes, or RN notification, ensuring safe and targeted care.
The nurse is suctioning an adult's tracheostomy tube. What action is essential before starting to suction the client?
- A. Have the client drink a glass of water to liquefy secretions
- B. Administer high levels of oxygen to the client
- C. Have the client sign a permit for suctioning
- D. Give the client a pad of paper and a pencil so he can communicate while the nurse suctions
Correct Answer: B
Rationale: Pre-oxygenation with high oxygen levels prevents hypoxia during tracheostomy suctioning, critical for patient safety, unlike water, consents, or communication aids.
The nurse is talking with a client who has human immunodeficiency virus (HIV). Which of the following statements by the client would indicate a correct understanding of the condition? Select all that apply.
- A. I should receive the influenza vaccine every year
- B. I will ask my roommate to clean the cat litter box for me
- C. I should ask for my steak to be cooked thoroughly with no pink inside
- D. I can eat the raw vegetables I grew in my garden if my HIV viral load is undetectable
- E. I will use bottled water when brushing my teeth if I travel to an area with poor sanitation
Correct Answer: A,B,C,E
Rationale: Flu vaccine, avoiding cat litter (toxoplasmosis risk), thorough cooking, and bottled water in unsanitary areas reduce infection risk in HIV. Raw vegetables pose a risk, even with undetectable viral load.
The nurse is assessing a client with delayed wound healing. Which of the following risk factors is most important in this situation?
- A. Glucose level of 120
- B. History of myocardial infarction
- C. Long term steroid usage
- D. Diet high in carbohydrates
Correct Answer: C
Rationale: Long term steroid usage. Steroids delay wound healing by impairing the inflammatory response.
The nurse is planning care for a client who is taking cyclosporin (Neoral). What would be an appropriate nursing diagnosis for this client?
- A. Alteration in body image
- B. High risk for infection
- C. Altered growth and development
- D. Impaired physical mobility
Correct Answer: B
Rationale: Cyclosporin (Neoral) inhibits normal immune responses. Clients receiving cyclosporin are at risk for infection.