A nurse is caring for a client who is prescribed cyclosporine.
Which of the following findings should the nurse report to the provider immediately?

The client requests to have grapefruit juice.

Increased serum bilirubin level.

The client reports hair growth on their body.

Blood pressure 128/82 mm Hg.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Grapefruit juice contains compounds that inhibit cytochrome P450 3A4 (CYP3A4) enzymes in the small intestine. Cyclosporine is metabolized by CYP3A4. Concomitant ingestion of grapefruit juice can lead to increased serum cyclosporine levels, raising the risk of toxicity, including nephrotoxicity and neurotoxicity.

Choice B rationale

An increased serum bilirubin level can indicate liver dysfunction, which is a potential adverse effect of cyclosporine. However, without specific values or other symptoms, this finding alone might not be an immediate emergency, though it warrants further investigation to assess liver health. Normal total bilirubin is 0.3 to 1.2 mg/dL.

Choice C rationale

Hair growth (hirsutism) is a common and recognized side effect of cyclosporine therapy, particularly in women. While it can be bothersome cosmetically, it is generally not indicative of an immediate or life-threatening adverse event and does not require urgent reporting.

Choice D rationale

A blood pressure of 128/82 mm Hg is slightly elevated but generally considered within an acceptable range, although on the higher side of normal. Cyclosporine can cause hypertension, but this specific reading does not represent a hypertensive crisis or an immediate emergency requiring urgent intervention.

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Correct Answer is A

Explanation

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.

A. Urine output of 240 mL in a 12-hr period. B. BUN 18 mg/dL (10 to 20 mg/dL). C. Weight loss of 0.61 Kg (1.34 Ib) in 24 hr. D. Blood pressure 100/70 mm Hg.

Correct Answer is C

Explanation

Choice A rationale

A urine output of 240 mL in a 12-hour period translates to 20 mL/hr, which is significantly below the normal physiological range of 30 mL/hr or greater. While low urine output can indicate dehydration, severe oliguria often points to acute kidney injury or severe hypovolemia, not solely dehydration. Normal urine output is generally considered to be 0.5-1 mL/kg/hr.

Choice B rationale

A BUN of 18 mg/dL falls within the normal range of 10 to 20 mg/dL. In dehydration, the kidneys reabsorb more water, leading to a disproportionate increase in BUN relative to creatinine due to increased urea concentration in the tubules, reflecting hypovolemia. A normal BUN value does not indicate dehydration.

Choice C rationale

A weight loss of 0.61 Kg (1.34 lb) in 24 hours is a significant and rapid reduction in body mass. This acute fluid deficit directly reflects a negative fluid balance, indicating a loss of body water. Each kilogram of weight loss approximates 1 liter of fluid loss, making this a clear indicator of dehydration due to fluid volume deficit.

Choice D rationale

A blood pressure of 100/70 mm Hg is within the normal range for many individuals, although it is on the lower side of normotension. While hypotension can be a late sign of severe dehydration, especially orthostatic hypotension, a reading of 100/70 mm Hg alone does not definitively confirm dehydration as the primary cause.

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A nurse is caring for a client who is prescribed cyclosporine. Which of the following findings should the nurse report to the provider immediately?

Nursing Test Bank

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A nurse is caring for a client who is prescribed cyclosporine.
Which of the following findings should the nurse report to the provider immediately?