A nurse is reviewing a client's peak and trough levels of gentamicin. The peak should be 6 to 8 mcg/mL and the trough should be 0.5 to 1 mcg/mL. The client's peak is10 mcg/mL and his trough is 2.3 mcg/mL. Which of the following clinical manifestations should the nurse expect with these findings? (Select all that apply.)
Insomnia
Constipation
Xerostomia
Persistent headache
Tinnitus
Correct Answer : D,E
D. Persistent headache can occur with elevated levels of gentamicin, as it may indicate neurotoxicity. Gentamicin can cause neurotoxic effects, including headaches, especially when levels are elevated.
E. Tinnitus (ringing in the ears) is a classic symptom of gentamicin toxicity. Elevated gentamicin levels can lead to ototoxicity, which manifests as tinnitus among other auditory symptoms.
A. Insomnia is not typically associated with elevated levels of gentamicin. Elevated gentamicin levels are not known to cause insomnia.
B. Constipation is not typically associated with elevated levels of gentamicin. Elevated gentamicin levels are not known to cause constipation.
C. Xerostomia (dry mouth) is not typically associated with elevated levels of gentamicin. Elevated gentamicin levels are not known to cause xerostomia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Infiltration occurs when IV fluid or medication leaks into the surrounding tissues rather than entering the vein. Coolness, blanching (pale appearance), swelling, and discomfort at the IV site are common signs of infiltration.
B. Local inflammation at the IV site can occur due to irritation or infection. Redness, warmth, swelling, tenderness, and possibly purulent drainage (pus) are typical signs. The description of a cool and blanched IV site does not fit the typical signs of inflammation, which usually involve warmth and redness.
C. Thrombophlebitis is inflammation of a vein with associated blood clot formation. Pain, warmth, redness, and swelling along the path of the vein are common. Thrombophlebitis typically presents with warmth and redness at the site, whereas the cool and blanched appearance described by the student suggests fluid infiltration rather than a thrombus causing inflammation.
D. Phlebitis is inflammation of the vein itself. Pain, redness, warmth, and swelling directly over the vein. Phlebitis usually manifests with warmth and redness, which are not present in the described symptoms.
Correct Answer is A
Explanation
A. Cleansing the injection site is important to reduce the risk of infection.
B. Sterile gloves are not typically required for administering subcutaneous injections unless there is a specific indication, such as when dealing with a client who has a compromised immune system or if there is potential for exposure to bodily fluids.
C. Pinching the skin can help in creating a fold where the needle can be inserted. However, there is no standard recommendation on which hand should be used.
D. Subcutaneous injections are typically administered at a 45-degree or 90-degree angle to the client's skin, depending on the amount of subcutaneous tissue present.
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