A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take to maintain medical asepsis?

Monitoring a client receiving aminoglycoside therapy for pyelonephritis involves close observation for signs of toxicity, especially affecting the kidneys, ears, and neuromuscular system. Gentamicin is effective against serious infections such as pyelonephritis but carries significant risk for ototoxicity and neuromuscular blockade. Early identification of adverse effects is essential to prevent permanent damage, particularly to hearing and neuromuscular function.

Rationale:
A. Chvostek’s sign is associated with hypocalcemia and neuromuscular irritability, not gentamicin toxicity. It is typically seen in conditions affecting calcium balance, such as hypoparathyroidism. Therefore, it is not an expected adverse effect of this medication.

B. Slurred speech may indicate neuromuscular blockade, a serious adverse effect of Gentamicin. Aminoglycosides can interfere with neuromuscular transmission, leading to muscle weakness, respiratory depression, and bulbar symptoms such as dysarthria. This finding requires immediate intervention as it may precede respiratory compromise.

C. Constipation is not a typical adverse effect of gentamicin. Aminoglycosides more commonly affect renal function and cranial nerve VIII rather than gastrointestinal motility. Therefore, this finding is unrelated to drug toxicity.

D. Hypertension is not a characteristic adverse effect of gentamicin. The drug is more strongly associated with nephrotoxicity, ototoxicity, and neuromuscular blockade rather than changes in blood pressure regulation. Monitoring should focus on renal function and neurologic status instead.

Management of hypoglycemia in a client with Type 1 diabetes mellitus involves rapid recognition and prompt administration of fast-acting carbohydrates to restore blood glucose levels. Mild hypoglycemia commonly presents with symptoms such as shakiness, sweating, hunger, irritability, or dizziness when blood glucose falls below normal levels. The priority treatment for a conscious client is administration of rapidly absorbable carbohydrates that can quickly raise serum glucose. Timely intervention helps prevent progression to severe neurological impairment or loss of consciousness.

Rationale:
A. Glucagon injection is typically reserved for severe hypoglycemia when the client is unconscious, unable to swallow safely, or experiencing seizures. Since the adolescent has only mild symptoms and is presumably alert enough to take oral carbohydrates, injectable glucagon is unnecessary at this stage. Oral treatment is preferred for mild hypoglycemic episodes.

B. One teaspoon of sugar alone does not provide an adequate amount of carbohydrate to effectively correct hypoglycemia. Standard treatment recommendations usually involve approximately 15 g of rapid-acting carbohydrate. A single teaspoon contains too little glucose and may not raise serum glucose sufficiently or rapidly enough.

C. A glass of orange juice is appropriate because it contains rapidly absorbed simple carbohydrates that quickly increase blood glucose levels. Fruit juice is commonly recommended for conscious clients experiencing mild hypoglycemia due to its fast onset of action. This intervention follows the “15-15 rule” commonly used in hypoglycemia management.

D. Peanut butter is not appropriate for immediate correction of hypoglycemia because its fat and protein content slows glucose absorption. Although it may help maintain glucose levels after initial correction, it does not act quickly enough to treat acute low blood sugar. Rapid-acting carbohydrates are needed first.