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Which action should the nurse include in the plan of care for a client who is receiving acyclovir (Zovirax) IV for the treatment of herpes zoster (shingles)?
- A. Initiate cardiac telemetry monitoring
- B. Maintain continuous pulse oximetry
- C. Perform capillary glucose measurements
- D. Monitor serum creatinine levels
Correct Answer: D
Rationale: The correct answer is to monitor serum creatinine levels. Acyclovir can potentially impact kidney function, making it essential to monitor serum creatinine levels to assess renal function. Option A, initiating cardiac telemetry monitoring, is not directly related to acyclovir administration for herpes zoster. Option B, maintaining continuous pulse oximetry, is more relevant in assessing respiratory status rather than monitoring for acyclovir-related side effects. Option C, performing capillary glucose measurements, is not directly associated with acyclovir therapy for herpes zoster.
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The nurse is planning care for a client with a stage III pressure ulcer. Which intervention is most important for the nurse to include in the plan of care?
- A. Reposition the client every 2 hours
- B. Cleanse the ulcer with normal saline
- C. Apply a moisture-retentive dressing
- D. Measure the ulcer's depth and diameter
Correct Answer: D
Rationale: The correct answer is to measure the ulcer's depth and diameter. This intervention is crucial as it helps monitor healing progress and evaluate the effectiveness of the care plan. Measuring the ulcer provides valuable information about the wound's improvement or deterioration. Repositioning the client every 2 hours (Choice A) is important for preventing further skin breakdown but may not be the priority in this case. Cleansing the ulcer with normal saline (Choice B) is essential for wound care but not the most crucial intervention at this stage. Applying a moisture-retentive dressing (Choice C) can promote healing, but assessing the ulcer's dimensions is more critical for monitoring progress.
A client who is gravida 1, para 0, is admitted to the birthing suite in early labor and requests pain relief. Which action should the nurse implement?
- A. Encourage the client to use distraction techniques
- B. Offer to teach the client relaxation techniques
- C. Determine the client's pain level and location
- D. Administer an opioid analgesic as prescribed
Correct Answer: D
Rationale: In this scenario, the correct action for the nurse to implement is to administer an opioid analgesic as prescribed. Since the client is in early labor and requesting pain relief, opioids are commonly used to provide effective pain relief during labor. Encouraging distraction or teaching relaxation techniques may not be sufficient for pain management during labor, especially in the early stages when the pain intensity can increase rapidly. Determining the pain level and location is important but administering the prescribed opioid is the most appropriate action to address the client's request for pain relief.
A client is leaving the hospital against medical advice (AMA) and voluntarily signs the AMA form. Which nursing action is essential prior to the client leaving?
- A. Remove the client's peripheral IV access
- B. Administer requested pain relief medication
- C. Obtain the client's neurological vital signs
- D. Provide the client with the hospital's phone number
Correct Answer: A
Rationale: Removing the client's peripheral IV access is essential before the client leaves against medical advice to prevent complications such as infection, thrombosis, or bleeding. Administering pain relief medication (choice B) can be important but not essential at this point. Obtaining neurological vital signs (choice C) is not specifically required before the client leaves. Providing the client with the hospital's phone number (choice D) may be helpful but is not as essential as ensuring the safe removal of IV access.
A male client admitted three days ago with respiratory failure is intubated, and 40% oxygen per facemask is initiated. Currently, his temperature is 99°F, capillary refill is less than 4 seconds, and respiratory effort is within normal limits. What outcome should the nurse evaluate to measure for successful extubation?
- A. Exhibits adequate tissue perfusion
- B. Remains free of injury
- C. Remains free of infection
- D. Maintains effective breathing pattern
Correct Answer: D
Rationale: Successful extubation relies on the patient's ability to maintain an effective breathing pattern. This indicates that the patient can adequately oxygenate and ventilate without the need for mechanical support. Monitoring tissue perfusion, preventing infection, and ensuring safety are important but not directly related to the immediate criteria for successful extubation. Tissue perfusion, injury prevention, and infection control are crucial aspects of overall patient care but are not the primary factors to consider when evaluating readiness for extubation.
In the newborn nursery, the nurse admits a baby from labor and delivery who is suspected of having a congenital heart disease. Which finding helps to confirm this diagnosis?
- A. Pink lips and tongue with cyanotic hands and feet
- B. Respiration rate of 40 and heart rate of 144
- C. Centralized cyanosis and tachycardia when crying
- D. Desquamation from areas of cracked, parchment-like skin
Correct Answer: C
Rationale: Centralized cyanosis and tachycardia are classic signs of congenital heart disease. Choice A is incorrect because cyanosis in the hands and feet is not specific to congenital heart disease. Choice B is incorrect as the vital signs provided are not specific indicators of congenital heart disease. Choice D is unrelated to the typical signs of congenital heart disease.