A client in the psychiatric unit's dayroom is becoming agitated, talking incessantly, and starting to yell and swear at the other clients.

Which action should the practical nurse (PN) implement first?

The correct answer is choice B: Monitor the client's hearing. Choice A rationale:

Observing the skin for a rash is not relevant to assessing for signs of ototoxicity. Aminoglycosides can cause skin reactions, but this is not a specific sign of ototoxicity.

Choice B rationale:

Monitoring the client's hearing is essential when administering aminoglycosides because these medications can cause ototoxicity, which is damage to the inner ear and auditory nerve leading to hearing loss or tinnitus. Regular hearing assessments can help detect any changes in hearing and prompt appropriate interventions.

Choice C rationale:

Measuring the urinary output is not directly related to assessing for ototoxicity.

Aminoglycosides can cause kidney toxicity, but this is a separate concern from ototoxicity. Choice D rationale:

Checking for changes in vision is not specifically associated with aminoglycoside administration. Vision changes are not a common side effect of these medications, so it would not be a primary assessment in this situation.

The correct answer is choiceB. Verify completion of all new prescriptions. This task is crucial to ensure patient safety and proper medication administration.

Choice A rationale:

Clean up and organize the nurses’ workstation: While maintaining an organized workstation is important for efficiency and reducing stress, it is not the highest priority task. Patient safety and care tasks take precedence over organizational tasks.

Choice B rationale:

Verify completion of all new prescriptions: This is the highest priority because verifying new prescriptions ensures that patients receive the correct medications as prescribed by their healthcare providers.This step is critical to prevent medication errors, which can have serious or even fatal consequences. Ensuring the accuracy of medication orders directly impacts patient safety and care quality.

Choice C rationale:

Calculate and record intake and output totals: Monitoring and recording intake and output is important for assessing a patient’s fluid balance and overall health status. However, this task can be delegated to another team member and does not take precedence over verifying medication orders, which is more time-sensitive and directly related to patient safety.

Choice D rationale:

Write a narrative shift summary for each client: Documenting a shift summary is essential for continuity of care and communication between healthcare providers. However, this task can be completed after ensuring that all critical patient care tasks, such as verifying new prescriptions, are addressed first.