A nurse is caring for a child who is to receive the first dose of IV gentamicin. Which of the following actions should the nurse take?
Monitor for constipation.
Maintain strict 1&O.
Initiate airborne precautions.
Encourage bed rest.
The Correct Answer is B
A. "Monitor for constipation." Constipation is not a common adverse effect of gentamicin. More concerning side effects include nephrotoxicity and ototoxicity.
B. "Maintain strict I&O." Gentamicin can cause nephrotoxicity, so it is essential to monitor intake and output (I&O) closely to assess kidney function and detect early signs of renal impairment.
C. "Initiate airborne precautions." Gentamicin is an antibiotic and does not require airborne precautions. Airborne precautions are used for infections like tuberculosis, measles, and varicella.
D. "Encourage bed rest." Gentamicin does not require bed rest. However, if the child experiences dizziness due to ototoxicity (another adverse effect), activity may need to be limited.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Perform a sterile dressing change 8 hr after the procedure." The initial dressing should be left in place for at least 24 hours, and any dressing changes should be performed per facility protocol.
B. "Keep the affected extremity straight for 4 hr." After a femoral venous cardiac catheterization, the child should keep the affected extremity straight for about 4 to 6 hours to prevent bleeding or hematoma formation at the insertion site.
C. "Assess the pulses above the catheterization site." The pulses below the site (distal pulses) should be assessed, not above. This is important to check for adequate circulation and potential complications such as clot formation or arterial obstruction.
D. "Maintain NPO status for 24 hr following the procedure." The child should typically resume oral intake as soon as they are fully awake and able to tolerate fluids, usually within a few hours post-procedure.
Correct Answer is B
Explanation
A. "Introduce solid foods when the infant reaches 3 months of age." Solid foods should be introduced around 4 to 6 months of age, when the infant shows signs of readiness (e.g., sitting with support, loss of tongue-thrust reflex).
B. "Offer 1 tablespoon as a serving size for the infant's solid food." A general guideline is 1 tablespoon of food per year of age per serving, so for an infant just starting solids, 1 tablespoon is appropriate per meal.
C. "Add 1 teaspoon of honey to the infant's bottle of formula if constipation occurs." Honey should not be given to infants under 1 year old due to the risk of botulism.
D. "Introduce the infant to a new solid food every other day." New foods should be introduced one at a time, every 3 to 5 days, to monitor for potential allergic reactions.
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