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A client with a diagnosis of acquired immunodeficiency syndrome and cytomegalovirus retinitis is receiving ganciclovir. Which action should the nurse plan to take while the client is taking this medication?
- A. Monitor blood glucose levels for elevation.
- B. Administer the medication on an empty stomach only.
- C. Apply pressure to venipuncture sites for at least 2 minutes.
- D. Provide the client with a soft toothbrush and an electric razor.
Correct Answer: D
Rationale: Ganciclovir causes neutropenia and thrombocytopenia as the most frequent side effects. For this reason, the nurse monitors the client for signs and symptoms of bleeding and implements the same precautions that are used for a client receiving anticoagulant therapy. These include providing a soft toothbrush and electric razor to minimize the risk of trauma that could result in bleeding. The medication may cause hypoglycemia, not hyperglycemia. The medication does not have to be taken on an empty stomach. Venipuncture sites should be held for approximately 10 minutes.
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A client is admitted with severe abdominal pains and the diagnosis of acute pancreatitis. The nurse should develop a plan of care during the acute phase of pancreatitis that will involve interventions targeting which of the following problems?
- A. Drug and alcohol abuse.
- B. Risk for injury.
- C. Severe pain.
- D. Ineffective airway clearance.
Correct Answer: C
Rationale: Severe pain is a primary concern in acute pancreatitis, requiring targeted interventions like analgesics.
When a daily dose of fluoxetine hydrochloride is prescribed for a client, the nurse provides instructions regarding its administration. Which statement by the client indicates an understanding regarding the administration of the medication?
- A. I should take the medication with food only.
- B. It is best to take the medication in the morning.
- C. I should take the medication at bedtime with a snack.
- D. I should take the medication at noontime with an antacid.
Correct Answer: B
Rationale: A daily dose of fluoxetine hydrochloride, a selective serotonin reuptake inhibitor (SSRI), should be taken in the morning. If the medication is prescribed more than once daily, then the client is instructed to take the last dose of the day before 4:00 pm to avoid insomnia. It does not have to be taken with food. Antacids are avoided with its administration because the antacid will affect absorption.
A nurse is planning care for a 7-year-old who is hospitalized for a hernia repair. The nurse should assess the client for which of the following fears common in this age group?
- A. Separation from parents.
- B. Trying something new.
- C. Injury and pain.
- D. Opposite-sex relationships.
Correct Answer: C
Rationale: School-age children (7 years) commonly fear injury and pain, especially in medical settings, due to their growing awareness of bodily harm.
A client with a history of osteoporosis is prescribed alendronate (Fosamax). The nurse should instruct the client to take the medication:
- A. At bedtime with a snack.
- B. First thing in the morning with water.
- C. With meals to enhance absorption.
- D. With milk to reduce stomach irritation.
Correct Answer: A
Rationale: Alendronate should be taken first thing in the morning with water, on an empty stomach, to maximize absorption and minimize esophageal irritation.
What type of immunity occurs when a person has an infectious, communicable disease like the measles?
- A. Adaptive immunity
- B. Passive natural immunity
- C. Active natural immunity
- D. Active artificial immunity
Correct Answer: C
Rationale: Active natural immunity occurs when a person develops immunity after exposure to an infectious disease like measles, producing antibodies through natural infection.