A nurse is preparing to administer vancomycin to a client who has an infected wound. The nurse should plan to monitor for which of the following adverse reactions?

Hepatotoxicity

Ototoxicity

Hypercalcemia

Hypertension

Answer and Explanation

The Correct Answer is B

A. Hepatotoxicity: Vancomycin is not commonly associated with liver toxicity. While liver function may be monitored in clients receiving multiple medications, hepatotoxicity is not a primary concern with vancomycin therapy.

B. Ototoxicity: Vancomycin can cause ototoxicity, particularly with high doses or prolonged therapy. This adverse effect may present as tinnitus or hearing loss, making it important for the nurse to monitor the client’s auditory function during treatment.

C. Hypercalcemia: Vancomycin does not affect calcium metabolism, so hypercalcemia is not an expected adverse reaction. Monitoring calcium levels is not routinely necessary for vancomycin administration.

D. Hypertension: Hypertension is not a known adverse effect of vancomycin. Blood pressure monitoring is standard for overall care, but vancomycin itself does not typically cause elevations in blood pressure.

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Correct Answer is C

Explanation

A. Holding the newborn in an en face position: Positioning the newborn face-to-face with the parent promotes eye contact and bonding. This action supports healthy attachment and is encouraged during early interactions.

B. Asking the father to change the newborn's diaper: Involving another caregiver in newborn care is appropriate and promotes family bonding. It does not indicate a problem with maternal-infant attachment.

C. Viewing the newborn's actions to be uncooperative: Interpreting normal newborn behaviors, such as crying or squirming, as deliberate uncooperativeness may indicate difficulty in bonding or unrealistic expectations. The nurse should intervene to provide guidance on normal newborn behavior and support attachment.

D. Requesting the nurse take the newborn to the nursery so she can rest: Asking for rest is appropriate, especially if the mother is fatigued. Temporary separation does not negatively impact bonding if the mother is able to interact and care for the newborn afterward.

A. Administer terbutaline subcutaneously as needed for contractions. B. Monitor the client's blood pressure every 2 hr. C. Place suction equipment at the client's bedside. D. Notify the provider of a urinary output of less than 50 mL/hr.

Correct Answer is C

Explanation

A. Administer terbutaline subcutaneously as needed for contractions: Terbutaline is a tocolytic used to suppress preterm labor, not to manage preeclampsia or magnesium sulfate therapy. Its use is unrelated to the care of a client receiving magnesium sulfate for seizure prophylaxis.

B. Monitor the client's blood pressure every 2 hr: In severe preeclampsia, blood pressure should be monitored more frequently than every 2 hours—typically every 15–30 minutes initially—because rapid changes can occur, and close monitoring is critical to prevent complications.

C. Place suction equipment at the client's bedside: Magnesium sulfate can cause respiratory depression as a serious adverse effect. Having suction equipment readily available ensures immediate intervention if the client experiences decreased respiratory effort or airway compromise, making this an essential safety measure.

D. Notify the provider of a urinary output of less than 50 mL/hr: While low urine output can indicate magnesium accumulation or renal impairment, the typical threshold for concern is less than 30 mL/hr. Although monitoring output is important, immediate bedside readiness for respiratory support is the priority intervention when administering magnesium sulfate.

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A nurse is preparing to administer vancomycin to a client who has an infected wound. The nurse should plan to monitor for which of the following adverse reactions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is observing bonding between a client and her newborn. Which of the following actions by the client requires the nurse to intervene?

Correct Answer is C

Explanation

A nurse is planning care for a client who has preeclampsia with severe features and is receiving magnesium sulfate via continuous IV infusion. Which of the following interventions should the nurse plan to include?

Correct Answer is C

Explanation

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