A nurse is assessing a client who is taking beclomethasone. Which of the following findings is the priority to report to the provider?
White coating in the mouth.
Nausea.
Myalgia.
Headache.
The Correct Answer is A
Choice A rationale
A white coating in the mouth can indicate oral thrush, a common side effect of inhaled corticosteroids like beclomethasone. This requires prompt treatment to prevent further complications.
Choice B rationale
Nausea is a less common side effect of beclomethasone and is not as urgent as oral thrush.
Choice C rationale
Myalgia (muscle pain) is a less common side effect and not as critical as oral thrush.
Choice D rationale
Headache is a common side effect but not as urgent as oral thrush.
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Correct Answer is ["A","B","D","E"]
Explanation
Choice A rationale
Contacting the provider is essential to inform them of the error and receive further instructions on managing the client’s condition.
Choice B rationale
Reporting the error to the charge nurse is necessary for proper documentation and to ensure that corrective actions are taken to prevent future errors.
Choice C rationale
Incident reports should not be placed in the client’s chart. They are for internal use to improve safety and quality of care.
Choice D rationale
Auscultating the client’s lungs is important to check for signs of fluid overload, such as crackles or wheezing.
Choice E rationale
Checking for peripheral edema helps assess the extent of fluid overload and its impact on the client’s condition.
Correct Answer is ["C","E"]
Explanation
Choice A rationale
Monitoring glucose levels is not typically necessary for patients receiving gentamicin, as it does not significantly affect glucose metabolism.
Choice B rationale
Prothrombin time is not commonly affected by gentamicin, so routine monitoring is not required.
Choice C rationale
Serum creatinine levels should be monitored to assess kidney function, as gentamicin can cause nephrotoxicity.
Choice D rationale
Cardiac enzymes are not typically affected by gentamicin, so routine monitoring is not necessary.
Choice E rationale
Monitoring WBC count is important to detect any signs of infection or bone marrow suppression, which can occur with gentamicin use.