A nurse is preparing to administer vancomycin to a client who has an infected wound. The nurse should plan to monitor for which of the following adverse reactions?

Hepatotoxicity

Ototoxicity

Hypercalcemia

Hypertension

Answer and Explanation

The Correct Answer is B

A. Vancomycin is not typically associated with hepatotoxicity.

B. Ototoxicity, which can manifest as hearing loss or tinnitus, is a potential adverse reaction of vancomycin therapy, especially with prolonged or high-dose therapy. Monitoring for signs of hearing impairment is essential.

C. Hypercalcemia is not a common adverse reaction associated with vancomycin therapy.

D. Hypertension is not a common adverse reaction associated with vancomycin therapy.

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Correct Answer is B

Explanation

A. An air leak noted at the insertion site would result in continuous bubbling in the water seal chamber, not the absence of tidaling.

B. If the tubing is kinked or obstructed, it can prevent the movement of air in and out of the water seal chamber, leading to the absence of tidaling.

C. If water needs to be added to the suction-control chamber, this would affect the level of suction, not the tidaling in the water seal chamber.

D. If the suction is set too low, it would not necessarily affect the tidaling in the water seal chamber; instead, it would result in inadequate drainage or lack of suction.

A. Insert the catheter until a flow of urine begins. B. Attach prefilled syringe to indwelling catheter inflation hub. C. Lubricate the catheter and place fenestrated drape over perineum. D. Apply sterile gloves and place cleansing balls in antiseptic solution. E. Cleanse the meatus with the dominant hand in a downward motion.

Correct Answer is D,C,E,A,B

Explanation

D. Apply sterile gloves and place cleansing balls in antiseptic solution.

C. Lubricate the catheter and place fenestrated drape over perineum.

E. Cleanse the meatus with the dominant hand in a downward motion.

A. Insert the catheter until a flow of urine begins.

B. Attach prefilled syringe to indwelling catheter inflation hub.

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A nurse is preparing to administer vancomycin to a client who has an infected wound. The nurse should plan to monitor for which of the following adverse reactions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the recovery room is assessing a client who has a new chest tube. The nurse finds that the water seal is no longer tidaling. The nurse should identify the finding as resulting from which of the following?

Correct Answer is B

Explanation

A nurse is preparing to insert an indwelling urinary catheter for a female client. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is D,C,E,A,B

Explanation

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