a nurse is caring for a client receiving vancomycin which of the following should the nurse monitor
Logo

Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment 2020 B

1. A client is receiving vancomycin. Which of the following should the nurse monitor?

Correct answer: B

Rationale: The correct answer is B: Serum creatinine. Vancomycin is known to be nephrotoxic, meaning it can cause kidney damage. Monitoring serum creatinine levels is essential to assess kidney function and detect any signs of nephrotoxicity. Blood glucose levels (choice A) are not directly affected by vancomycin. INR levels (choice C) are typically monitored for clients on anticoagulants, not vancomycin. Liver function tests (choice D) are not primarily affected by vancomycin use; kidney function is of greater concern.

2. A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine. Which of the following interventions should the nurse include in the plan?

Correct answer: B

Rationale: The correct answer is to monitor the client’s skin under the halo vest. This is important to assess for signs of skin issues such as excessive sweating, redness, or blistering, which can lead to skin breakdown and infection. Choice A is incorrect because inspecting the pin site every 4 hours is necessary but not the priority in this case. Choice C is incorrect as it is not essential for two personnel to hold the halo device during repositioning. Choice D is incorrect because applying powder frequently can actually increase the risk of skin issues by clogging pores and causing irritation.

3. A client who is 28 weeks pregnant and has preeclampsia is being cared for by a nurse. Which of the following is the priority assessment?

Correct answer: C

Rationale: Blood pressure is the priority assessment in clients with preeclampsia because hypertension is the primary symptom of the condition. Elevated blood pressure increases the risk of complications such as eclampsia and placental abruption. Assessing the blood pressure helps in monitoring the severity of the preeclampsia and guiding appropriate interventions. While monitoring the client's level of consciousness, deep tendon reflexes, and urinary output are important, they are secondary assessments in the context of preeclampsia.

4. A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider?

Correct answer: C

Rationale: Jaundice within the first 24 hours of life is considered pathological and may indicate hemolytic disease or another serious condition, requiring further investigation.

5. A healthcare provider is teaching a client about the use of prednisone. Which of the following should be included?

Correct answer: B

Rationale: The correct answer is B. Prednisone can cause weight gain and other side effects, so clients should be informed about these potential risks. Choice A is incorrect because prednisone should not be stopped abruptly to prevent withdrawal symptoms. Choice C is incorrect because prednisone can have various side effects. Choice D is incorrect because prednisone is usually prescribed with specific dosing instructions and should not be taken irregularly or only when symptoms occur.

Similar Questions

A nurse is reviewing the medication class, benzodiazepines. The nurse would use caution when administering benzodiazepines to which of the clients below?
A nurse is planning care for a group of postoperative clients. Which of the following interventions should the nurse identify as the priority?
A nurse is caring for a client who has a peripherally inserted central catheter (PICC). For which of the following findings should the nurse notify the provider?
A nurse is assessing a client who has anemia. Which of the following findings should the nurse expect?
A healthcare provider is preparing to transfer a client from a chair to the bed. The client can bear partial weight and has upper body strength. Which device should the healthcare provider use?

Access More Features

ATI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses