Nokea
A client with AIDS is taking Zovirax (acyclovir). Which nursing intervention is most critical during the administration of acyclovir?
- A. Limit the client's activity
- B. Encourage a high-carbohydrate diet
- C. Utilize an incentive spirometer to improve respiratory function
- D. Encourage fluids
Correct Answer: D
Rationale: Acyclovir can cause nephrotoxicity, so encouraging fluids is critical to prevent kidney damage.
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Which one of the following situations represents a maturational crisis for the family?
- A. A 4-year-old entering nursery school
- B. Development of preeclampsia during pregnancy
- C. Loss of employment and health benefits
- D. Hospitalization of a grandfather with a stroke
Correct Answer: A
Rationale: A 4-year-old entering nursery school is a maturational crisis, as it involves a normal developmental transition that can stress family dynamics.
A client in cardiac arrest is given 40 units of vasopressin (Pitressin) IV push. The nurse knows the desired action of this medication in a cardiac arrest is to
- A. raise blood pressure.
- B. stop cardiac arrhythmia.
- C. lower blood pressure.
- D. reset the electrical cardiac conduction system.
Correct Answer: A
Rationale: Vasopressin, used in cardiac arrest, is a vasopressor that raises blood pressure by vasoconstriction, improving perfusion during CPR.
Which of the following are risk factors for developing glaucoma? Select all that apply.
- A. asthma
- B. pernicious anemia
- C. diabetes mellitus
- D. obesity
- E. hypertension
Correct Answer: C,E
Rationale: Diabetes mellitus and hypertension increase glaucoma risk by affecting ocular blood flow and pressure. Asthma, anemia, and obesity are not direct risk factors.
A client in labor has an order for Demerol (meperidine) 75 mg. IM to be administered 10 minutes before delivery. The nurse should:
- A. Wait until the client is placed on the delivery table and administer the medication
- B. Question the order
- C. Give the medication IM during the delivery to prevent pain from the episiotomy
- D. Give the medication as ordered
Correct Answer: B
Rationale: Administering meperidine 10 minutes before delivery risks neonatal respiratory depression, so the nurse should question the order.
The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select?
- A. Roast beef, gelatin salad, green beans, and peach pie
- B. Chicken salad sandwich, coleslaw, French fries, ice cream
- C. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie
- D. Pork chop, creamed potatoes, corn, and coconut cake
Correct Answer: A
Rationale: Roast beef is a good source of heme iron, which is more easily absorbed, making this meal plan the best choice for a client with iron-deficiency anemia.