A nurse is caring for a client who has a bacterial infection and is receiving gentamicin. Which of the following actions should the nurse take to minimize the risk of an adverse effect of the medication?
Administer the medicine with food.
Monitor the serum medication levels.
Limit the client’s fluid intake.
Instruct the client to report agitation.
The Correct Answer is B
The correct answer is choice b. Monitor the serum medication levels.
Choice A rationale:
Administering gentamicin with food is not necessary and does not minimize the risk of adverse effects. Gentamicin is typically given intravenously or intramuscularly, and food does not impact its administration or absorption.
Choice B rationale:
Monitoring the serum medication levels is crucial when administering gentamicin. Gentamicin has a narrow therapeutic index, meaning the difference between a therapeutic dose and a toxic dose is small. Regular monitoring helps ensure the drug remains within the safe and effective range, reducing the risk of nephrotoxicity and ototoxicity.
Choice C rationale:
Limiting the client’s fluid intake is not recommended. Adequate hydration is important to help prevent nephrotoxicity, a known adverse effect of gentamicin. Ensuring the client has sufficient fluid intake can help protect kidney function.
Choice D rationale:
Instructing the client to report agitation is not directly related to minimizing the risk of adverse effects of gentamicin. While it is important for clients to report any unusual symptoms, agitation is not a common adverse effect of gentamicin. Monitoring for signs of nephrotoxicity (e.g., decreased urine output) and ototoxicity (e.g., hearing loss, tinnitus) is more relevant.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Neuromuscular-blocking agents paralyze the muscles, including the respiratory muscles. Therefore, it is crucial to ensure that the patient maintains a patent airway and is able to breathe effectively. The nurse should monitor the patient's respiratory rate, depth, and effort, as well as assess for signs of airway obstruction, such as stridor or wheezing.
Skin assessment for rash (option b), blood pressure assessment for orthostatic hypotension (option c), and assessment for fluid volume overload (option d) may also be important assessments for the nurse to obtain, but they are not the most critical assessments when a patient is being treated with a neuromuscular-blocking agent.
Correct Answer is D
Explanation
When administering ophthalmic drops, the nurse should hold the dropper 2 cm (3/4 inch) above the lower conjunctival sac and instill the prescribed number of drops into the sac. The client should be instructed to look up and away from the dropper while the drops are being instilled.
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