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Hurst Practice Exam 2 Questions and Answers Latest update and A+ Guide A client has been prescribed vancomycin 1 gram IV every 12 hours for the treatment of methicillin-resistant staphylococcus aureus (MRSA). Which action by a new nurse when administering this medication would require intervention by the charge nurse? - ANSWER- This dose of medication should be delivered over at least 60 minutes to prevent hypotension and ototoxicity. The nurse is caring for a client taking benazepril. Which symptoms would be important for the nurse to report to the primary healthcare provider? -ANSWER- Weight gain of 5 pounds in one week is a s/s of an adverse effect of ACE inhibitor use. Weight gain is a sign of fluid retention. Angioedema is an adverse effect of ACE inhibitors and can be life threatening. This should be reported immediately to the healthcare provider. The potassium level is too high. Hyperkalemia is an adverse effect of an ACE inhibitor and needs to be reported. The nurse is caring for a client taking spironolactone. Which dietary change should the nurse teach the client to make when starting treatment with this medication? -ANSWERSpironolactone is a potassium sparing diuretic. Salt substitutes have potassium instead of sodium and should be avoided. When assessing a client, the nurse finds that in response to painful stimuli the upper extremities exhibit flexion of the arm, wrist, and fingers with adduction of the limb, while the lower extremity exhibits extension, internal rotation, and plantar flexion. How would the nurse accurately document this finding? -ANSWER- This describes decorticate posturing because they are moving towards the core of the body. Decerebrate posturing -ANSWER- when the client is stimulated, and teeth clench and the arms are stiffly extended, adducted, and hyperpronated. The legs are stiffly extended with plantar flexion of the feet. Abnormal extension occurs with lesions in the area of the brain stem. A client being treated for osteoporosis with alendronate reports experiencing slight heartburn after taking the medicine. What should the nurse suggest to reduce this side effect? -ANSWER- Increased heartburn can be reduced or prevented by drinking plenty of water, sitting upright following the administration of the medication, and avoiding sucking on the tablet.

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