The nurse is administering the sixth IV dose of gentamicin to a client with extensive full thickness burns. Which assessment finding warrants further intervention?

Reference Range:

White Blood Cell [5000 to 10,000/mm3 (5 to 10 x 10 %/L)] Blood Urea Nitrogen [10 to 20 mg/dL (3.6 to 7.1 mmol/L)] Creatinine [0.5 to 1.1 mg/dL (44 to 97 µmol/L)]

Serum creatinine level of 1.6 mg/l. (141 µmol), a blood urea nitrogen (BUN) of 20 mg/dL.(7.1 mmol/L)

Reports a sore mouth and three episodes of diarrhea that began this morning.

White blood count of 9,000/mm3 (9 x 109/L) and an oral temperature of 98.2° F (36.7° C) two hours ago.

Urinary output of 400 ml of clear, amber colored urine in the past eight hours.

Answer and Explanation

The Correct Answer is A

A. Serum creatinine level of 1.6 mg/dL (141 µmol/L), a blood urea nitrogen (BUN) of 20 mg/dL (7.1 mmol/L): Gentamicin is an aminoglycoside that is known for its nephrotoxic potential. Elevated serum creatinine and BUN levels are indicative of impaired kidney function, which warrants further investigation and possible intervention. This finding is significant because it may reflect kidney damage or reduced renal clearance of the drug.
B. Reports a sore mouth and three episodes of diarrhea that began this morning: While these symptoms are important and could suggest a possible adverse effect or secondary infection, they are not as immediately concerning in the context of gentamicin therapy as the potential for kidney damage indicated by elevated creatinine and BUN levels.
C. White blood count of 9,000/mm³ (9 x 10^9/L) and an oral temperature of 98.2°F (36.7°C) two hours ago: These values are within normal ranges and do not suggest an immediate concern related to gentamicin toxicity.
D. Urinary output of 400 mL of clear, amber-colored urine in the past eight hours: While monitoring urinary output is important, this level of output does not necessarily indicate a problem in the context of gentamicin therapy compared to elevated creatinine and BUN levels.

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Correct Answer is C

Explanation

A. Frequently assess the client’s blood pressure: While monitoring blood pressure is important, it is not as critical as monitoring the ECG in cases of diltiazem overdose. Diltiazem is a calcium channel blocker that can lead to significant cardiac effects.
B. Observe the client for signs of gastric irritation: This is relevant for some medications, but in the case of diltiazem overdose, the primary concern is the potential for severe cardiac effects rather than gastric irritation.
C. Monitor electrocardiogram (ECG) continuously: Diltiazem overdose can lead to serious cardiac arrhythmias, such as bradycardia, AV block, or other conduction disturbances. Continuous ECG monitoring is crucial to detect these potentially life-threatening complications.
D. Assess for changes in level of consciousness: While important, changes in level of consciousness are secondary to the immediate need to monitor cardiac function closely in the context of diltiazem overdose.

A. Fingerstick glucose. B. Stool color and character. C. Serum hepatic enzymes. D. Serum electrolytes and ammonia.

Correct Answer is D

Explanation

A. Fingerstick glucose: While important in managing diabetes or hypoglycemia, it is not directly related to evaluating the effectiveness of lactulose in treating hepatic encephalopathy.
B. Stool color and character: Lactulose acts as a laxative, and its effectiveness can affect stool characteristics. However, stool color and character are less direct indicators of therapeutic response compared to serum ammonia levels.
C. Serum hepatic enzymes: While liver enzyme levels can provide information about liver function, they do not directly measure the effectiveness of lactulose in managing hepatic encephalopathy. Serum ammonia levels are more specific for this purpose.
D. Serum electrolytes and ammonia: Lactulose is used to treat hepatic encephalopathy by reducing blood ammonia levels. Monitoring serum ammonia levels provides direct feedback on the effectiveness of the medication in treating hepatic encephalopathy. Additionally, serum electrolytes should be monitored because lactulose can lead to electrolyte imbalances due to its laxative effect.

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Naxlex Comprehensive Predictor Exams

A male client with dementia is admitted to the emergency department (ED) because he accidentally self-administered several doses of diltiazem. Which intervention is most important for the nurse to implement?

Correct Answer is C

Explanation

A client with hepatic encephalopathy is receiving lactulose. Which assessment provides the nurse with the best information to evaluate the client's therapeutic response to the medication?

Correct Answer is D

Explanation

A client is receiving morphine sulfate via a patient-controlled analgesia (PCA) pump postoperatively. Which assessment finding should prompt the nurse to administer a prescribed PRN dose of naloxone?

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During a home visit, a client informs the nurse about feeling like the heart is skipping beats. When reviewing the client's record, the nurse notes that the client is taking hydrochlorothiazide. Based on these assessment data, the nurse plans to obtain a blood sample to check for which condition?

Prior to administering oral doses of calcitriol and calcium carbonate to a client with hypoparathyroidism, the nurse notes that the client's total calcium level is 14 mg/dl (3.5 mmol/l) Which action should the nurse implement? Reference Range: Calcium 8.5 to 10.5 mg/dL (2.25 to 2.75 mmol/L)

Which instruction should the nurse include when teaching a client about self-administration of a bulk-forming laxative?

The nurse is assessing the eyes of a client who just received mydriatic eye drops. Which physiological function of the eye will not respond during the therapuetic period after administration of the eye drops?