A patient is receiving vancomycin. Which physiological function is the priority for the nurse to assess?

Vision

Heart tones

Bowel sounds

Hearing

Answer and Explanation

The Correct Answer is D

A. Vision is not commonly affected by vancomycin, so it is not a priority to assess.
B. Heart tones are not directly impacted by vancomycin and do not require immediate monitoring unless there are specific cardiovascular concerns.
C. Bowel sounds are not directly influenced by vancomycin and do not need to be prioritized in this case.
D. Vancomycin is known to be ototoxic, especially in high doses or with prolonged use, so monitoring for signs of hearing loss or tinnitus is essential to prevent potential irreversible damage.

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Correct Answer is D

Explanation

A. The nursing diagnosis "Impaired physical mobility" is appropriate and does not need revision.
B. There is no collaborative problem mentioned in the statement that requires revision.
C. The defining characteristic "patient's inability to ambulate" accurately reflects the patient's current condition and does not need changes.
D. The etiology "related to tibial fracture" should be revised to reflect a more precise causal factor that can be addressed by nursing interventions. A more appropriate etiology could specify the limitation in mobility rather than just stating the fracture.

A. A patient with hypercapnia wearing an oxygen mask B. A patient with a chest tube ambulating with the chest tube unclamped C. A patient with thick secretions being tracheal suctioned first and then orally D. A patient with a new tracheostomy and tracheostomy obturator at bedside

Correct Answer is B

Explanation

A. A patient with hypercapnia requires monitoring, but wearing an oxygen mask indicates some level of intervention is in place.
B. A patient with a chest tube should never ambulate with the chest tube unclamped, as this can lead to a collapsed lung and respiratory distress; thus, this patient should be prioritized.
C. While a patient with thick secretions may need suctioning, this is not as critical as ensuring the safety of a patient with an unclamped chest tube.
D. A patient with a new tracheostomy requires monitoring, but the presence of the obturator indicates readiness for emergencies; this does not take priority over the safety of the patient with the chest tube.

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A patient is receiving vancomycin. Which physiological function is the priority for the nurse to assess?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing a patient's plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?

Correct Answer is D

Explanation

A nurse is caring for a group of patients. Which patient should the nurse see first?

Correct Answer is B

Explanation

A nurse is providing passive range of motion (ROM) for a patient with impaired mobility. Which technique will the nurse use for each movement?

A nurse is assessing a patient with prolonged stress. Which conditions will the nurse monitor for in this patient? (Select all that apply.)

The nurse is planning to administer a tuberculin test with a 27-gauge, 5/8-inch needle. At which angle will the nurse insert the needle?

A patient is experiencing carbon dioxide retention from lung problems. Which type of diet will the nurse most likely suggest for this patient?

Which patients will the nurse determine are in most need of regular perineal care? (Select all that apply.)

The nurse is assessing a new patient admitted to home health. Which questions will be most appropriate for the nurse to ask to determine the risk of infection? (Select all that apply.)