A nurse is caring for a client who has a prescription for acyclovir IV three times daily.
Which of the following actions should the nurse take?

Assess for an increase in creatinine.

Administer oxygen prophylactically.

Assess for a decrease in Hgb and Hct.

Administer the medication over 30 min.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Acyclovir is primarily excreted renally, and its metabolism can lead to crystal formation in the renal tubules, particularly if the client is dehydrated or the infusion is too rapid. Monitoring for an increase in creatinine (normal range 0.6-1.2 mg/dL) is crucial as it indicates decreased glomerular filtration rate and potential nephrotoxicity or acute kidney injury, necessitating dose adjustment or hydration.

Choice B rationale

Administering oxygen prophylactically is not a standard or scientifically indicated action for acyclovir administration. Acyclovir does not inherently cause respiratory depression or compromise oxygenation. Its primary adverse effects are typically related to renal function, central nervous system, or gastrointestinal system, not respiratory compromise.

Choice C rationale

While some antiviral medications can affect hematopoiesis, acyclovir is not commonly associated with significant decreases in hemoglobin (normal range 12-18 g/dL) and hematocrit (normal range 37-52%). These parameters are generally monitored in clients with pre-existing hematological conditions or those on long-term, high-dose therapy, but it's not a primary immediate concern for IV administration.

Choice D rationale

Administering acyclovir IV over 30 minutes is the recommended infusion duration. Rapid intravenous infusion can increase the risk of renal tubular damage and crystal formation, leading to nephrotoxicity. A slower infusion rate allows for proper dilution and minimizes the concentration of the drug in the renal tubules, thus protecting kidney function and reducing adverse effects.

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Correct Answer is ["E"]

Explanation

Choice A rationale: Persistent coughing with mucopurulent sputum suggests an ongoing respiratory infection or inflammation. Mucopurulent sputum indicates the presence of neutrophils and bacteria, often seen in bacterial pneumonia or tuberculosis. While significant, coughing alone is not an immediate life-threatening finding but rather a symptom requiring monitoring and further diagnostic follow-up to confirm the cause.

Choice B rationale: Joint pain in a patient receiving infliximab for rheumatoid arthritis may reflect an autoimmune flare or side effects of immunosuppression. Although uncomfortable and significant for quality of life, joint pain does not usually require immediate intervention compared to respiratory or infectious signs that may threaten life or transmission risk.

Choice C rationale: Anorexia, or decreased appetite, is a common systemic symptom in chronic infections like tuberculosis. It reflects the body’s inflammatory response and catabolic state but is a nonspecific finding. It requires addressing nutritional support but is not immediately life-threatening or requiring urgent intervention compared to active infectious disease signs.

Choice D rationale: Night sweats are a classic systemic symptom of tuberculosis caused by cytokine-mediated thermoregulatory dysfunction during infection. Although important in clinical suspicion, night sweats themselves do not necessitate immediate intervention but support the need for further diagnostic workup and infection control precautions.

Choice E rationale: An 11 mm induration on the purified protein derivative (PPD) test is considered positive in this patient due to immunosuppression with infliximab, which increases TB risk. The normal cutoff varies by risk factors, but 5 mm or greater is positive in immunosuppressed patients. This finding requires urgent follow-up to initiate treatment and prevent active disease and transmission, making it the most critical.

A. Blood glucose. B. Iron. C. Alanine aminotransferase. D. Thyroid-stimulating hormone. E. Hemoglobin.

Correct Answer is ["B","E"]

Explanation

Choice A rationale

Blood glucose levels are not directly impacted by epoetin alfa. Epoetin alfa stimulates erythropoiesis, the production of red blood cells, and its effectiveness is assessed by parameters related to red blood cell mass and oxygen-carrying capacity, not glucose metabolism.

Choice B rationale

Iron levels are crucial to monitor when a client is receiving epoetin alfa. Epoetin alfa stimulates red blood cell production, which requires adequate iron stores for hemoglobin synthesis. Insufficient iron can limit the therapeutic response to epoetin alfa.

Choice C rationale

Alanine aminotransferase (ALT) levels are indicators of liver function. Epoetin alfa does not have a direct hepatotoxic effect, and therefore, monitoring ALT is not a primary method to assess its effectiveness. Liver enzyme levels are not directly related to erythropoiesis.

Choice D rationale

Thyroid-stimulating hormone (TSH) levels are indicators of thyroid function. Epoetin alfa does not directly influence thyroid hormone production or regulation, and monitoring TSH would not provide information about the medication's effectiveness in stimulating red blood cell production.

Choice E rationale

Hemoglobin levels are the primary laboratory test to monitor the effectiveness of epoetin alfa. The medication's purpose is to stimulate erythropoiesis, leading to an increase in red blood cell mass and subsequently, a rise in hemoglobin concentration (normal range for adult males: 13.5–17.5 grams/dL; for adult females: 12.0–15.5 grams/dL).

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A nurse is caring for a client who has a prescription for acyclovir IV three times daily. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["E"]

Explanation

A nurse is reviewing the medical record of a client who is taking epoetin alfa. Which of the following laboratory tests should the nurse monitor to determine the effectiveness of the medication? Select all that apply.

Correct Answer is ["B","E"]

Explanation

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A nurse is caring for a client who has a prescription for acyclovir IV three times daily.
Which of the following actions should the nurse take?