The nurse is caring for a client who has an order for no food or drink by mouth and is receiving intravenous acyclovir. To prevent nephrotoxicity, what is the nurse's action?
Encourage oral fluid intake during the infusion and for 2 hours after the infusion.
Monitor urinary output every 30 minutes.
Provide a low-protein diet for one day before and two days after the acyclovir infusion.
Administer intravenous normal saline boluses, as ordered.
The Correct Answer is A
a. This is the correct answer because maintaining adequate hydration helps prevent nephrotoxicity associated with acyclovir. Encouraging fluid intake during and after the infusion helps flush the drug through the kidneys.
b. While monitoring urinary output is important, it alone may not be sufficient to prevent nephrotoxicity.
c. Providing a low-protein diet is not a standard intervention for preventing acyclovir-induced nephrotoxicity.
d. Administering intravenous normal saline boluses, as ordered, can help maintain hydration and prevent nephrotoxicity. However, encouraging oral fluid intake is a more direct and immediate measure during acyclovir infusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
a) Checking blood sugar once daily or more is a proactive and accurate self-management practice for individuals with diabetes.
b) Glipizide does not contain sulfa, so having a sulfa allergy is not a contraindication for taking this medication. The client needs clarification on this point.
c) Taking glipizide once daily with breakfast is a reasonable dosing schedule.
d) Having a glass of wine with dinner may be acceptable, but moderation and monitoring for interactions are advisable.
Correct Answer is C
Explanation
A) Hydroxyzine is an antihistamine that can reduce redness, itching, and edema.
B) While nausea can be a side effect, it is not the primary concern with hydroxyzine.
C) Avoiding alcohol is important as it can enhance the sedative effects of hydroxyzine.
D) Hydroxyzine is known for its sedative effects, and sedation is a common side effect that the client should be aware of.
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