1. A 94-year-old patient is receiving gentamicin sulfate (Garamycin) in a continuous intravenous
(IV) infusion. The nurse adds to the nursing care plan the patient problem “Potential injury.” What nursing action should be implemented?
a. Pull side rails in place.
b. Assist with ambulation.
...
1. A 94-year-old patient is receiving gentamicin sulfate (Garamycin) in a continuous intravenous
(IV) infusion. The nurse adds to the nursing care plan the patient problem “Potential injury.”
What nursing action should be implemented?
a. Pull side rails in place.
b. Assist with ambulation.
c. Measure intake and output.
d. Provide for a possible seizure.
ANS: C
Reduced urine output would cause the drug to stay in the system rather than being excreted,
which could result in a drug saturation. Gentamicin is ototoxic and can cause hearing
impairment.
2. A 75-year-old patient reports to a nurse that although she has cleaned her ears with
cotton-tipped applicators for weeks, she still cannot hear her television unless the volume is
loud, and she misses a great deal of conversations. What should the nurse anticipate when
examining her ears?
a. Otitis externa
b. Purulent drainage
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