A client with acquired immunodeficiency syndrome (AIDS) is prescribed zidovudine (azidothymidine, AZT [retrovir]), 200mg PO every 4 hours. When teaching the client about this drug, the nurse should provide which instruction?
- A. “Take zidovudine with meals.”
- B. “Take zidovudine on an empty stomach.”
- C. “Take zidovudine every 4 hours around the clock.”
- D. “Take over-the-counter(OTC) drugs to treat minor adverse reactions.”
Correct Answer: C
Rationale: The correct answer is C: "Take zidovudine every 4 hours around the clock." Zidovudine is an antiretroviral medication used to treat HIV/AIDS. It is crucial for the client to adhere to the prescribed dosing schedule to maintain therapeutic blood levels. Taking the medication every 4 hours around the clock helps to ensure consistent levels in the body, maximizing its efficacy. Taking it with meals (choice A) or on an empty stomach (choice B) is not specifically indicated for zidovudine. Choice D is incorrect as taking OTC drugs without consulting a healthcare provider can lead to drug interactions or adverse effects. Hence, choice C is the most appropriate instruction to ensure the client benefits from the medication.
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Which of the ff symptoms is associated with AIDS related distal sensory polyneuropathy (DSP)?
- A. Staggering gait and muscle incoordination
- B. Abnormal sensations such as burning and numbness
- C. Delusional thinking
- D. Incontinence
Correct Answer: B
Rationale: The correct answer is B: Abnormal sensations such as burning and numbness. In AIDS-related DSP, damage to nerves causes abnormal sensations like burning and numbness. This is due to the progressive nerve damage affecting sensory functions. Staggering gait and muscle incoordination (A) are more common in conditions affecting motor nerves. Delusional thinking (C) is not a symptom of DSP. Incontinence (D) is not typically associated with DSP but may happen in more advanced stages due to loss of sensation.
Nursing intervention during the lumbar puncture procedure includes:
- A. Monitoring Mrs. GC’s color, pulse and respiration
- B. Labeling all laboratory specimens in numerical order
- C. Positioning Mrs. GC on her side with knees drawn up to her chest
- D. All of the above
Correct Answer: D
Rationale: Step 1: Monitoring Mrs. GC's color, pulse, and respiration is important to assess for any signs of distress during the procedure.
Step 2: Labeling all laboratory specimens in numerical order ensures accurate identification and prevents errors in specimen handling.
Step 3: Positioning Mrs. GC on her side with knees drawn up to her chest helps maintain proper spinal alignment and reduces the risk of complications.
Summary: Option D is correct because all the interventions mentioned are crucial for ensuring patient safety and procedural success. Options A, B, and C are incorrect individually as they each address only one aspect of the procedure, whereas the correct answer encompasses all necessary interventions.
When the nurse is reviewing a patient’s daily laboratory test results, which of the ff. electrolyte imbalances should the nurse recognize as predisposing the patient to digoxin toxicity?
- A. Hypokalemia
- B. Hyponatremia
- C. Hyperkalemia
- D. Hypernatremia
Correct Answer: A
Rationale: Step-by-step rationale:
1. Digoxin toxicity can be potentiated by hypokalemia due to the risk of enhanced cardiac toxicity.
2. Hypokalemia can lead to increased sensitivity of cardiac cells to digoxin.
3. Low potassium levels can disrupt the sodium-potassium ATPase pump, enhancing digoxin's effects.
4. The nurse should recognize hypokalemia as a predisposing factor for digoxin toxicity.
Summary:
A: Hypokalemia is the correct answer as it enhances digoxin toxicity by affecting cardiac function.
B: Hyponatremia does not directly predispose to digoxin toxicity.
C: Hyperkalemia is not a predisposing factor and can actually counteract digoxin's effects.
D: Hypernatremia is not directly related to digoxin toxicity.
A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care?
- A. Posttrauma syndrome
- B. Constipation
- C. Acute pain
- D. Anxiety
Correct Answer: C
Rationale: The correct answer is C: Acute pain. This is the most pertinent nursing diagnosis because the patient has a right femur fracture and reports moderate discomfort. The priority is to address the acute pain associated with the fracture. Posttrauma syndrome (A) typically involves a broader range of emotional and psychological responses beyond just moderate discomfort. Constipation (B) is not the priority in this case, as it is not directly related to the patient's current condition. Anxiety (D) may be present but addressing the acute pain takes precedence in this situation to ensure the patient's comfort and well-being.
During a routine check-up, the nurse evaluates a client with rheumatoid arthritis. To assess for the most obvious disease manifestations first, the nurse checks for:
- A. Muscle weakness
- B. Painful subcutaneous nodules
- C. Joint abnormalities
- D. Gait disturbances
Correct Answer: C
Rationale: The correct answer is C: Joint abnormalities. In rheumatoid arthritis, joint abnormalities such as swelling, warmth, and tenderness are the hallmark manifestations. Assessing joint abnormalities first is crucial as they are the primary clinical signs of the disease. Muscle weakness (A) is a common symptom but typically occurs later due to joint inflammation and disuse. Painful subcutaneous nodules (B) are present in some cases but are not as common or prominent as joint abnormalities. Gait disturbances (D) may occur as a result of joint damage, but they are secondary to the primary manifestation of joint abnormalities. By prioritizing the assessment of joint abnormalities, the nurse can promptly identify and address the most prevalent disease manifestations in rheumatoid arthritis.