Nokea
A nurse is applying silver sulfadiazine to a client's burn. Which of the following would be important for the nurse to do? Select all that apply.
- A. Clean and remove debris from the burned area before application
- B. Allow air drafts over the burn area to speed the healing process
- C. Apply a 1/2-inch-thick layer of cream to the burn
- D. Wear sterile gloves when applying the cream to the burn
- E. Warn client of burning sensation during and shortly following application
Correct Answer: A,D,E
Rationale: When applying silver sulfadiazine cream to a burn, clean and remove debris from the burned area, apply cream while wearing sterile gloves, apply a 1/16-inch-thick layer to the area, keep the client away from air drafts to decrease pain, and warn the client that he or she may experience a burning sensation during and shortly following cream application.
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After teaching a group of nursing students about the action of sulfonamides, the instructor determines that the teaching was successful when the students state that the action of this class of drugs is primarily which of the following?
- A. Bacteriostatic
- B. Bactericidal
- C. Promotor of folic acid activity
- D. Bacterial cell metabolizer
Correct Answer: A
Rationale: The sulfonamides are primarily bacteriostatic because of their ability to inhibit the activity of folic acid in bacterial cell metabolism. They are not bactericidal.
When developing the plan of care for a client receiving sulfonamides for treatment of a urinary tract infection, the nurse identifies actions for encouraging fluid intake and monitoring intake and output based on which nursing diagnosis?
- A. Risk for Fluid Imbalance
- B. Impaired Urinary Elimination
- C. Risk for Ineffective Renal Perfusion
- D. Stress Incontinence
Correct Answer: B
Rationale: A client with a urinary tract infection already is experiencing an alteration in urinary elimination. Because one adverse effect of the sulfonamide drugs is altered elimination patterns, it is important to help the client maintain adequate fluid intake and output. The nurse would encourage clients to increase fluid intake to 2000 mL or more per day to prevent crystalluria and stones (calculi) forming in the genitourinary tract, as well as to aid in removing microorganisms from the urinary tract. It is important to measure and record the client's intake and output every 8 hours and notify the primary health care provider if the urinary output decreases or the client fails to increase his or her oral intake. If the client is unable to maintain adequate intake, then he or she would be at risk for fluid imbalance. If renal injury would occur, then the client would be at risk for ineffective renal perfusion. Bladder training would be an appropriate intervention to address stress incontinence.
A client who is being discharged has been instructed to continue with sulfonamide therapy for a week. Which of the following points should the nurse include in the teaching plan to educate the client about the therapy?
- A. Discontinue dosage if symptoms of infection disappear.
- B. Take the drug a few minutes before a meal.
- C. Take any off-the-shelf medication if fever occurs.
- D. Ensure that all follow-up appointments are met
Correct Answer: D
Rationale: The nurse's plan should include educating the client about the importance of keeping the follow-up appointments. The nurse should instruct the client to adhere to the dosage schedule and not discontinue it even if the symptoms of the infection have gone. The client should inform the primary health care provider if fever, skin rash, or nausea occurs during the therapy. The client should be instructed to take the drug on an empty stomach (at least 2 hours before or after a meal) and not just before a meal.
A client who is on sulfonamide therapy is about to be discharged. Which of the following precautions should the nurse instruct the client to follow to reduce the effects of photosensitivity?
- A. Wear protective clothing and sunscreen when outside.
- B. Increase fluid intake.
- C. Avoid lights while indoors.
- D. Wear protective footwear
Correct Answer: A
Rationale: The nurse should encourage a client to wear protective clothing while going out in the sun to reduce the effect of photosensitivity. While increasing the fluid intake is recommended, it does not help combat the effects of photosensitivity. There is no need to avoid lights while indoors; the skin becomes sensitive only to harsh sunlight during sulfonamide therapy. Wearing protective footwear may protect the feet from injury, but it will not protect the skin from the harmful effects of photosensitivity.
A client with a fever is ordered to receive sulfonamide therapy for an infection. The nurse needs to evaluate the client for which of the following during the course of therapy? Select all that apply.
- A. Response to drug therapy
- B. Elevated blood glucose levels
- C. Mental status changes
- D. Occurrence of adverse reactions
- E. Decrease in temperature
Correct Answer: A,D,E
Rationale: During the course of therapy, the nurse evaluates the client at periodic intervals for response to the drug, including relief of symptoms and decrease in temperature, as well as the occurrence of any adverse reactions.