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. Vancomycin is not typically associated with hepatotoxicity.

B. Ototoxicity, which can manifest as hearing loss or tinnitus, is a potential adverse reaction of vancomycin therapy, especially with prolonged or high-dose therapy. Monitoring for signs of hearing impairment is essential.

C. Hypercalcemia is not a common adverse reaction associated with vancomycin therapy.

D. Hypertension is not a common adverse reaction associated with vancomycin therapy.

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Correct Answer is A

Explanation

A. The priority action is to remove the client from the source of carbon monoxide poisoning, which in this case is the kerosene space heater. Taking the client outdoors will provide fresh air and reduce exposure to carbon monoxide.

B. Wrapping blankets around the client may further exacerbate the symptoms by trapping the carbon monoxide, worsening the client's condition.

C. While loosening the client's clothing may improve ventilation, it is not as effective as removing the client from the source of exposure.

D. Opening the client's windows may help improve ventilation, but it is not as effective as taking the client outdoors to reduce exposure to carbon monoxide.

A. Perform another internal exam. B. Notify the client's provider. C. Check the FHR. D. Obtain a pH test of the fluid.

Correct Answer is C

Explanation

A. Performing another internal exam is not the priority at this moment. The priority is assessing fetal well-being.

B. Notifying the client's provider may be necessary, but it is not the immediate priority.

C. Checking the fetal heart rate (FHR) is the priority action to assess fetal well-being after the observed fluid gush, as it could indicate rupture of membranes and potentially fetal distress.

D. Obtaining a pH test of the fluid can be done later for confirmation of rupture of membranes but is not the immediate priority compared to assessing fetal well-being.

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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 home health nurse is assessing a client who reports a headache and appears confused and drowsy. The client has a kerosene space heater in use. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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