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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

A client with Parkinson's disease is scheduled for stereotactic surgery. Which finding indicates that the surgery had its intended effect?

Correct Answer: A

Rationale: Stereotactic surgery, such as deep brain stimulation, aims to reduce symptoms like intractable tremors in Parkinson's disease. It does not directly increase dopamine or serotonin production, nor does it eliminate the need for medication entirely.

Question 3 of 5

The doctor has ordered Ampicillin 100 mg every six hours IV push for an infant weighing 7 kg. The suggested dose for infants is 25-50 mg/kg/day in equally divided doses. The nurse should:

Correct Answer: D

Rationale: The ordered dose (100 mg q6h = 400 mg/day) for a 7 kg infant is 57.14 mg/kg/day, exceeding the recommended 25-50 mg/kg/day. The nurse should verify the order to prevent overdose.

Question 4 of 5

The nurse is caring for a client with a history of a myocardial infarction who is receiving Nitroglycerin. The nurse should monitor the client for:

Correct Answer: A

Rationale: Nitroglycerin, a vasodilator, commonly causes hypotension due to decreased preload. Tachycardia is possible but secondary, and hyperglycemia/fever are unrelated.

Question 5 of 5

The nurse in the emergency room is caring for a client with multiple rib fractures and a pulmonary contusion. Assessment reveals a respiratory rate of 38, a heart rate of 136, and restlessness. Which associated assessment finding would require immediate intervention?

Correct Answer: C

Rationale: Subcutaneous air and absent breath sounds suggest pneumothorax, requiring immediate intervention (e.g., chest tube). Hemoptysis (
A), wheezing (
B), and pain/rales (
D) are concerning but less urgent.

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