A male client has been receiving the antibiotic gentamicin sulfate, IV piggyback every 12 hours for several days. Which observation by the nurse indicates that the client may be experiencing an adverse effect of gentamicin?
Reference Range: White Blood Cell [5000 to 10,000/mm3 (5 to 10 x 109/L)]
White blood cell count of 6,000/mm3 (6 x 109/L).
Decreased blood urea nitrogen.
Hearing has decreased.
Reports of photophobia.
The Correct Answer is C
Rationale:
A. A WBC count within the normal range does not indicate an adverse effect of gentamicin.
B. Gentamicin is more likely to increase BUN levels due to nephrotoxicity rather than decrease them.
C. Gentamicin is an aminoglycoside antibiotic known to cause ototoxicity, which can lead to hearing loss. Decreased hearing is a significant adverse effect that should be promptly addressed.
D. Photophobia is not a common side effect of gentamicin.
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Correct Answer is C
Explanation
Rationale:
A. Pneumonia typically presents with fever, productive cough, and lung consolidation, not just wheezing and low oxygen saturation.
B. Pneumothorax usually causes sudden sharp chest pain and decreased breath sounds on the affected side, rather than wheezing and prolonged expiration.
C. Asthma is characterized by wheezing, prolonged expiration, and low oxygen saturation due to bronchoconstriction and inflammation. The client's symptoms are consistent with an asthma exacerbation.
D. Bronchitis presents with a productive cough and sometimes wheezing but does not typically cause such severe hypoxemia or a pronounced increase in respiratory rate as seen here.
Correct Answer is C
Explanation
Rationale:
A. Dietary teaching is important for long-term health but does not address the immediate issue of dizziness upon standing.
B. Monitoring vital signs every 4 hours is important, but obtaining blood pressure before standing is crucial to prevent falls and manage orthostatic hypotension.
C. Measuring blood pressure before the client stands helps identify orthostatic hypotension, which could be causing weakness and dizziness.
D. Measuring urinary output is relevant but not immediately pertinent to the client's dizziness and weakness on standing.