A patient is scheduled to receive intravenous acyclovir.
What should the nurse do first before administering the scheduled dose?
Infuse the medication slowly, over a period of 60-90 minutes.
Dilute the acyclovir in 1 liter of normal saline.
Check the intravenous site for any signs of redness, heat, or swelling.
Examine the patient for any open herpetic lesions.
The Correct Answer is C
Choice A rationale
Infusing the medication slowly over a period of 60-90 minutes is a common practice for many intravenous medications to prevent adverse reactions. However, this is not the first step a nurse should take before administering intravenous acyclovir.
Choice B rationale
While diluting certain medications in a liter of normal saline can be a part of the preparation process, it is not the first step a nurse should take before administering intravenous acyclovir.
Choice C rationale
Checking the intravenous site for any signs of redness, heat, or swelling is the correct first step before administering any intravenous medication. This is to ensure that the IV site is not infected or inflamed, which could lead to complications such as phlebitis or infiltration.
Choice D rationale
Examining the patient for any open herpetic lesions is important when administering acyclovir, as the medication is used to treat herpes infections. However, this is not the first step a nurse should take before administering the medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While collecting a urine sample can be important in diagnosing certain conditions, it is not the most important action to take prior to administering an antibiotic for pneumonia.
Choice B rationale
Ensuring the patient is on a cardiac monitor is not the most crucial action prior to administering an antibiotic for pneumonia. While it’s important to monitor the patient’s vital signs, it’s not specifically related to the administration of antibiotics.
Choice C rationale
Collecting a blood culture sample is the most important action to take prior to administering an antibiotic for pneumonia. This is to identify the specific bacteria causing the infection, which can help in selecting the most effective antibiotic.
Choice D rationale
Checking baseline vital signs, including temperature, is important but not the most crucial action prior to administering an antibiotic for pneumonia. It’s part of the overall assessment but does not directly impact the choice or effectiveness of the antibiotic.
Correct Answer is D
Explanation
Choice A rationale
While continuous pulse oximetry can provide useful information about a patient’s oxygen saturation levels, it is not the most crucial step before administering amphotericin B. Amphotericin B is an antifungal medication used to treat serious, potentially life-threatening fungal infections. It does not directly affect oxygen saturation levels.
Choice B rationale
The rate at which amphotericin B is administered can be important, as the medication must be given slowly through an IV infusion, which can take from 2 to 6 hours to complete. However, setting the IV pump to deliver the medication over a specific span of time is not the most crucial step before administration.
Choice C rationale
Continuous cardiac monitoring can be important in certain situations, but it is not the most crucial step before administering amphotericin B. While amphotericin B can cause some side effects related to the heart, such as changes in heart rate or blood pressure, these are not typically the primary concerns before administration.
Choice D rationale
Evaluating the patient’s sodium and calcium levels is the most crucial step before administering amphotericin B. Amphotericin B can cause changes in electrolyte levels, including sodium and calcium. Monitoring these levels can help prevent potential complications, making this the most crucial step before administration.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.