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Questions 158

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Question 1 of 5

A female client has been hospitalized for several months following major abdominal surgery for a ruptured colon. A colostomy was created, and the large abdominal wound was left open and allowed to heal through granulation. She is receiving gentamicin IV for treatment of wound infection. Knowing this drug is ototoxic, the nurse would implement which of the following measures?

Correct Answer: A

Rationale: The first nursing measure is to instruct the client in which drug side effects to report. Discontinuing the drug is not an independent nursing intervention and may compromise client care. Audiometric testing will detect hearing loss, but it does not indicate a potential cause. Equalizing middle ear pressure will not prevent hearing loss.

Question 2 of 5

The nurse is caring for an adolescent with a five-year history of bulimia. A common clinical finding in the client with bulimia is:

Correct Answer: B

Rationale: Frequent vomiting in bulimia exposes teeth to stomach acid, leading to dental caries (tooth decay), a common clinical finding.

Question 3 of 5

A client with B negative blood requires a blood transfusion during surgery. If no B negative blood is available, the client should be transfused with:

Correct Answer: C

Rationale: O negative blood is the universal donor type, safe for all recipients, including B negative, as it lacks A, B, and Rh antigens, minimizing transfusion reactions.

Question 4 of 5

A client had a right below-the-knee amputation 4 days ago. He is complaining of pain in his right lower leg. The nurse should:

Correct Answer: D

Rationale: Phantom pain is a normal, very real experience for an amputee and should be treated with pain medication.

Question 5 of 5

The client with a history of epilepsy is prescribed valproic acid (Depakote). Which laboratory test should the nurse monitor?

Correct Answer: A

Rationale: Valproic acid can cause hepatotoxicity, so liver function tests (e.g., AST, ALT) are monitored regularly. Renal function, blood counts, and electrolytes are less commonly affected.

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