The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse to report to the healthcare provide?
Elevated liver function tests.
Vomiting and diarrhea.
Decreased white blood cell count.
Pruritus and muscle aches.
The Correct Answer is A
Rationale:
A. Elevated liver function tests: Oral antivirals such as acyclovir or valacyclovir are metabolized by the liver, and elevated liver enzymes may indicate hepatotoxicity. This finding is critical and may necessitate discontinuation or dose adjustment to prevent liver damage.
B. Vomiting and diarrhea: These are common side effects of oral antivirals and are usually self-limiting. They typically do not require discontinuation unless they lead to dehydration or are severe and persistent.
C. Decreased white blood cell count: A decreased white blood cell can be a side effect of some antiviral medications, and while it increases the risk of infection, it is usually monitored during long-term therapy. However, in the context of acute shingles treatment with an oral antiviral, elevated liver function tests often represent a more immediate concern.
D. Pruritus and muscle aches: These symptoms may occur with antiviral use but are usually mild and nonspecific. They should be monitored but are not as immediately concerning as signs of liver dysfunction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Low intermittent suction prescribed for the nasogastric tube is turned off: While nasogastric suction helps prevent gastric distention and vomiting, turning it off temporarily is not immediately dangerous. This should be addressed but does not pose an urgent risk if the client is stable.
B. The urinary catheter drainage bag is almost completely full of amber urine: Although the bag should be emptied to prevent backflow or tension on the catheter, amber urine is expected and not concerning. This is a routine task and does not indicate an urgent issue.
C. Oxygen is being administered via nasal cannula at 4 L/min without humidification:
Oxygen at this rate may cause nasal dryness if humidification is not used, but this does not create an immediate threat to client safety. It should be corrected, but it’s not the most critical concern.
D. A Hemovac drain is partially full of serous drainage and is not compressed: The Hemovac must remain compressed to provide negative pressure for continuous drainage. If not compressed, fluid can accumulate at the surgical site, increasing infection and hematoma risk. This requires prompt correction to prevent postoperative complications.
Correct Answer is A
Explanation
Rationale:
A. "Chest physiotherapy should be performed twice a day before a meal.” Chest physiotherapy helps clear mucus from the lungs and is most effective when done before meals to prevent vomiting and optimize lung function and oxygenation.
B. "Administer a cough suppressant every 8 hours." Cough suppressants are generally avoided in cystic fibrosis because coughing is necessary to mobilize and expel thick secretions from the airways.
C. "Energy should be conserved by scheduling minimally strenuous activities." Physical activity is encouraged to enhance lung expansion and mucus clearance. Energy conservation is not the priority unless the child is acutely ill.
D. "Maintain supplemental oxygen at 4 to 6 L/minute." High-flow oxygen is not routinely used and may suppress respiratory drive. Oxygen is used with caution and only as prescribed in advanced disease or during exacerbations.
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