A client is receiving intravenous gentamicin (Garamycin). Which of the following findings should prompt the nurse to notify the healthcare provider immediately?

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Hearing loss. Gentamicin is an aminoglycoside antibiotic known for its potential ototoxicity, which can result in irreversible damage to the inner ear and lead to hearing loss. Therefore, any signs of hearing impairment while the client is receiving gentamicin should be immediately reported to the healthcare provider to prevent further harm. A) Nausea is a common side effect of gentamicin but is not typically considered a reason for immediate notification unless it is severe or persistent. C) Headache is not a typical side effect associated with gentamicin administration. While it should be monitored, it is not a priority over potential ototoxicity. D) Diarrhea is another common side effect of gentamicin, but it is not as urgent as hearing loss in terms of potential complications. It can be managed with appropriate interventions and monitoring. Educationally, this question emphasizes the importance of understanding the adverse effects of specific medications, particularly those with serious implications like gentamicin-induced ototoxicity. It highlights the need for vigilant monitoring and prompt reporting of concerning findings to ensure patient safety and prevent further complications.

Correct Answer: C

Rationale: Furosemide (Lasix) is a diuretic that can lead to orthostatic hypotension, causing dizziness. Instructing the client to change positions slowly can help prevent this adverse effect. It is important for the client to consume foods rich in potassium to prevent hypokalemia. Taking furosemide in the morning helps reduce the need for frequent urination at night. Encouraging the client to maintain an adequate fluid intake is crucial to prevent dehydration while on this medication.

Correct Answer: C

Rationale: Heparin is an anticoagulant, so the primary potential complication is bleeding. The healthcare provider should monitor the client for signs of bleeding, such as bruising, hematuria, and gastrointestinal bleeding. Hypertension, tachycardia, and hyperkalemia are not direct complications of heparin therapy.

Correct Answer: C

Rationale: The nurse should instruct the client to apply the nitroglycerin (Nitro-Dur) transdermal patch at the same time each day to ensure consistent blood levels. It is essential to apply the patch to a hairless area of the skin for proper absorption. The patch can generally be left on during a shower. The patch is usually worn for 12-14 hours to allow for a nitrate-free period, which helps reduce tolerance to the medication.

Correct Answer: B

Rationale: The nurse should instruct the client to report a pulse rate less than 60 beats per minute, as it could indicate digoxin toxicity. Consuming potassium-rich foods is encouraged due to the potential for furosemide (Lasix) to cause hypokalemia. The medications should be taken in the morning to prevent nocturia. Additionally, the client should weigh themselves daily to monitor for fluid retention, which is crucial in managing heart failure.