Nokea
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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Which collaborative intervention should the nurse implement when caring for the client diagnosed with bronchiectasis?
- A. Prepare the client for an emergency tracheostomy.
- B. Discuss postoperative teaching for a lobectomy.
- C. Administer bronchodilators with postural drainage.
- D. Obtain informed consent form for chest tube insertion.
Correct Answer: C
Rationale: Bronchodilators with postural drainage (C) is a collaborative intervention for bronchiectasis to open airways and clear secretions, involving nursing and respiratory therapy. Tracheostomy (A) and lobectomy (B) are not standard. Chest tubes (D) are for pneumothorax, not bronchiectasis.
The nurse is assessing a patient, who has many risk factors for the development of a DVT, for signs and symptoms of a deep vein thrombosis. What signs and symptoms below would possibly indicate a deep vein thrombosis is present?
- A. Cool extremity
- B. Decreases pulses
- C. Redness
- D. Pain
- E. Warm extremity
- F. Swelling
- G. Cyanosis
Correct Answer: C,D,E,F
Rationale: Signs and symptoms of a DVT include: redness, swelling, warm extremity, pain, positive Homan's Sign, and swelling (which can be unilateral...meaning there is more swelling in one extremity compared to the other).
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.
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.