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Questions 158

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Question 1 of 5

Which of the following serum laboratory values would the nurse monitor during gentamicin therapy?

Correct Answer: A

Rationale: A common side effect of gentamicin is nephrotoxicity. The serum laboratory test that best reflects kidney function is serum creatinine.

Question 2 of 5

The most important reason to closely assess circumferential burns at least every hour is that they may result in:

Correct Answer: D

Rationale: Full-thickness circumferential burns are nonelastic and create an internal tourniquet effect, compromising distal blood flow in extremities or respiratory motion in the torso, leading to loss of peripheral pulses.

Question 3 of 5

The nurse is caring for a client with a history of heart failure. Which discharge instruction is most important?

Correct Answer: A

Rationale: Daily weight monitoring detects fluid retention early in heart failure, allowing timely intervention. Exercise should be moderate, sodium restricted, and pain relievers used cautiously.

Question 4 of 5

A client has viral encephalitis and has been prescribed IV acyclovir (Zovirax). What nursing interventions should be used when administering the drug?

Question Image

Correct Answer: A, B, C, E

Rationale: Acyclovir requires slow infusion (
A) to prevent phlebitis, adequate hydration (
B) to reduce nephrotoxicity, monitoring for neurotoxicity (
C), and caution in renal insufficiency (E). Heart rate (
D) is unrelated.

Question 5 of 5

The client at 34 weeks gestation is admitted with a diagnosis of gestational hypertension. Which assessment finding requires immediate intervention?

Correct Answer: C

Rationale: Absence of deep tendon reflexes in gestational hypertension suggests magnesium toxicity (if receiving magnesium sulfate) or severe neurological complications requiring immediate intervention. The other findings while concerning are less urgent.

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