Nokea
A client has viral encephalitis and has been prescribed IV acyclovir (Zovirax). What nursing interventions should be used when administering the drug?
- A. Administer at a slow rate.
- B. Assure the client is well hydrated before giving the drug.
- C. Observe for neurotoxicity.
- D. Check the apical heart rate prior to administration.
- E. Infuse cautiously in clients with renal insufficiency.
Correct Answer: A, B, C, E
Rationale: Acyclovir requires slow infusion (A) to prevent phlebitis, adequate hydration (B) to reduce nephrotoxicity, monitoring for neurotoxicity (C), and caution in renal insufficiency (E). Heart rate (D) is unrelated.
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The nurse is assessing breath sounds in a bronchovesicular client. She should expect that:
- A. Inspiration is longer than expiration
- B. Breath sounds are high pitched
- C. Breath sounds are slightly muffled
- D. Inspiration and expiration are equal
Correct Answer: D
Rationale: Inspiration is normally longer in vesicular areas. High-pitched sounds are normal in bronchial area. Muffled sounds are considered abnormal. Inspiration and expiration are equal normally in this area, and sounds are medium pitched.
A patient with thrombocytopenia has a platelet count of 80,000. It will be most important to teach the client about:
- A. Measures to reduce the risk of bleeding
- B. Increasing the fluid intake
- C. Activities to improve oxygenation
- D. Ways to conserve energy
Correct Answer: A
Rationale: Thrombocytopenia (low platelet count) increases bleeding risk. Teaching measures to reduce bleeding (e.g. avoiding trauma using soft toothbrushes) is critical. Fluid intake oxygenation and energy conservation are less directly related to the condition.
A client with a history of heart failure is receiving Spironolactone (Aldactone). The nurse should teach the client to:
- A. Avoid potassium-rich foods
- B. Increase sodium intake
- C. Take the medication at bedtime
- D. Limit fluid intake
Correct Answer: A
Rationale: Spironolactone, a potassium-sparing diuretic, risks hyperkalemia, so potassium-rich foods should be avoided. Sodium restriction, daytime dosing, and fluid management are secondary.
Chorioamnionitis is a maternal infection that is usually associated with:
- A. Prolonged rupture of membranes
- B. Postterm deliveries
- C. Maternal pyelonephritis
- D. Maternal dehydration
Correct Answer: A
Rationale: Chorioamnionitis is an inflammation of the chorion and amnion that is generally associated with premature or prolonged rupture of membranes.
The nurse is caring for a client with osteoporosis who is being discharged on alendronate (Fosamax). Which statement would indicate a need for further teaching?
- A. "I should take the medication immediately before bedtime every night."
- B. "I should remain in an upright position for 30 minutes after taking Fosamax."
- C. "The medication should be taken by mouth with water."
- D. "I should not have any food with this medication."
Correct Answer: A
Rationale: Alendronate should be taken in the morning on an empty stomach, not before bedtime (A), indicating a need for further teaching. Upright positioning (B), taking with water (C), and avoiding food (D) are correct.