A nurse is caring for a client who has HIV-1 infection and is prescribed zidovudine as part of antiretroviral therapy. The nurse should monitor the client for which of the following adverse effects of this medication?
Bone marrow suppression
Metabolic alkalosis
Hypoglycemia
Hyperkalemia
The Correct Answer is A
Choice A reason: Zidovudine, a nucleoside reverse transcriptase inhibitor, commonly causes bone marrow suppression, leading to anemia, neutropenia, or thrombocytopenia. It inhibits DNA synthesis in rapidly dividing bone marrow cells, reducing red blood cell, white blood cell, and platelet production. Monitoring complete blood counts is essential to detect these hematologic toxicities early and manage them appropriately.
Choice B reason: Metabolic alkalosis is not a known adverse effect of zidovudine. The drug primarily affects hematopoiesis and mitochondrial function, not acid-base balance. Metabolic alkalosis may occur in conditions like excessive vomiting or diuretic use, but zidovudine’s mechanism does not alter bicarbonate or pH levels, making this an unlikely complication.
Choice C reason: Hypoglycemia is not associated with zidovudine. The drug’s primary toxicities involve bone marrow and mitochondrial dysfunction, not glucose metabolism. Hypoglycemia may occur with other conditions or medications, like insulin, but zidovudine does not affect pancreatic function or glucose regulation, so monitoring for this is unnecessary in this context.
Choice D reason: Hyperkalemia is not a recognized side effect of zidovudine. The drug’s adverse effects center on hematologic and muscular systems, not electrolyte balance. Hyperkalemia may result from renal dysfunction or other medications, but zidovudine does not disrupt potassium homeostasis, so it is not a priority for monitoring in this patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Administering insulin infusion is the priority in DKA to correct hyperglycemia and halt ketogenesis. Insulin lowers blood glucose by facilitating cellular uptake and inhibits lipolysis, reducing ketone production. This addresses the underlying metabolic derangement, preventing further acidosis and stabilizing the patient’s condition rapidly, critical for life-threatening DKA.
Choice B reason: Providing oral glucose is contraindicated in DKA, as the client already has severe hyperglycemia. Adding glucose would worsen the condition, increasing osmotic diuresis and acidosis. The focus is on lowering blood sugar with insulin and fluids, not adding more glucose, which could exacerbate dehydration and metabolic imbalance.
Choice C reason: Sodium bicarbonate may be used in severe DKA with profound acidosis (pH < 7.0), but it is not the priority. Insulin and fluid resuscitation correct the underlying cause of acidosis by stopping ketone production and restoring perfusion. Bicarbonate is an adjunct and may cause complications like hypokalemia if used prematurely.
Choice D reason: Deep breathing exercises do not address the metabolic cause of DKA. While compensatory hyperventilation (Kussmaul respirations) occurs to correct acidosis, encouraging breathing exercises does not treat hyperglycemia or ketosis. Insulin and fluids are critical to reverse the underlying pathology, making breathing exercises a low-priority intervention in this acute condition.
Correct Answer is ["A","B","C"]
Explanation
Choice A reason: Frequent skin assessments allow early detection of pressure injury signs, such as non-blanchable redness or skin breakdown. By identifying at-risk areas like the sacrum or heels, nurses can implement preventive measures promptly. This reduces tissue ischemia from prolonged pressure, preventing progression to ulcers by ensuring timely intervention to protect skin integrity.
Choice B reason: Frequent turning and positioning relieve pressure on bony prominences, reducing ischemia and tissue damage. Repositioning every 2 hours promotes blood flow, preventing prolonged compression of capillaries, which leads to hypoxia and necrosis. This is a cornerstone of pressure injury prevention, especially in immobile patients with limited tissue perfusion.
Choice C reason: Optimizing nutrition ensures adequate protein and micronutrient intake, essential for tissue repair and maintenance. Malnutrition impairs collagen synthesis and immune function, increasing susceptibility to skin breakdown. Adequate caloric and protein intake supports skin integrity, reducing the risk of pressure injuries by enhancing tissue resilience and healing capacity.
Choice D reason: Maintaining the head of the bed at a 45-degree angle increases shear forces on the sacrum and coccyx, potentially exacerbating pressure injury risk. While it may aid respiratory function, it does not directly prevent pressure injuries and may contribute to skin breakdown in immobile patients due to increased frictional forces.
Choice E reason: Inspecting the sacrum for blanching is part of skin assessment but is not an intervention to reduce incidence. Blanching indicates intact capillary perfusion, but non-blanchable redness signals early damage. While useful for staging, it is a diagnostic step, not a preventive measure like repositioning or nutrition, which actively reduce pressure injury risk.
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