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You are about to hang a bag of intravenous Vancomycin for a patient who has severe pneumonia. Which statement by the patient causes you to hold the bag of Vancomycin and notify the doctor immediately?
- A. I'm seeing yellow halos around the light.'
- B. My mouth tastes like metal.'
- C. My head hurts.'
- D. I have this constant ringing in my ears.'
Correct Answer: D
Rationale: Ringing in the ears indicates potential ototoxicity, a serious vancomycin side effect requiring immediate cessation and physician notification. Other symptoms (A, B, C) are less specific and not immediately alarming.
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The employee health nurse is administering tuberculin skin testing to employees who have possibly been exposed to a client with active tuberculosis (Tb). Which statement indicates the need for radiological evaluation instead of skin testing?
- A. The client's first skin test indicates a purple flat area at the site of injection.
- B. The client's second skin test indicates a red area measuring four (4) mm.
- C. The client's previous skin test was read as positive.
- D. The client has never shown a reaction to the tuberculin medication.
Correct Answer: C
Rationale: A prior positive TB skin test (C) indicates exposure, requiring CXR to assess active disease, not repeat skin testing. Purple area (A) is normal, 4 mm (B) is negative, and no reaction (D) warrants testing.
If the client has sinusitis in the maxillary sinuses, where will the client most likely report feeling pain?
- A. Near the eyebrows
- B. In the cheeks
- C. Above the ears
Correct Answer: B
Rationale: The maxillary sinuses are located in the cheek area, so pain from maxillary sinusitis is typically felt in the cheeks.
Which of the following signs and symptoms would indicate that the client is experiencing oxygen toxicity? Select all that apply.
- A. Nonproductive cough
- B. Nausea
- C. Restlessness
- D. Headache
- E. Substernal chest pain
- F. Nasal stuffiness
Correct Answer: A, D, E
Rationale: Oxygen toxicity from prolonged high-concentration oxygen can cause a nonproductive cough, headache, and substernal chest pain.
The client is three (3) days post-partial laryngectomy. Which type of nutrition should the nurse offer the client?
- A. Total parenteral nutrition.
- B. Soft, regular diet.
- C. Partial parenteral nutrition.
- D. Clear liquid diet.
Correct Answer: D
Rationale: Clear liquids (D) are safest 3 days post-laryngectomy to prevent aspiration. TPN (A), soft diet (B), and partial PN (C) are premature or unnecessary.
You assist your patient with using their inhaler. The inhaler contains the medication Budesonide. Before administering the inhaler, you will want to connect what device to the inhaler to help decrease the patient from developing?
- A. Peak flow meter; pneumonia
- B. Incentive spirometer; thrush
- C. Spacer; thrush
- D. Peak flow meter; mouth sores
Correct Answer: C
Rationale: A spacer helps deliver Budesonide, an inhaled corticosteroid, more effectively to the lungs, reducing the risk of oral thrush by minimizing medication deposition in the mouth.