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
Related Questions
Correct Answer is A
Explanation
a. This is the correct answer. Oral acyclovir is considered safe during pregnancy and may be used to suppress outbreaks of genital herpes in pregnant women.
b. Using intravenous antiviral agents is typically reserved for severe cases and is not the first-line approach for suppressing outbreaks in pregnant women.
c. While topical acyclovir can be used for genital herpes outbreaks, it is not typically the first choice for suppression during pregnancy.
d. This statement is not accurate. Some antiviral medications, including oral acyclovir, are considered safe during pregnancy when the benefits outweigh the risks, especially in cases where there is a history of recurrent genital herpes.
Correct Answer is B
Explanation
a) The symptoms described are indicative of hypoglycemia, and addressing the client's emotional state or offering to listen does not address the immediate medical issue.
b) Checking the blood glucose level is crucial to determine if the symptoms are due to hypoglycemia, and providing carbohydrates can help raise the blood sugar level promptly.
c) Assuming a panic attack without assessing the potential hypoglycemic state could delay appropriate intervention.
d) The symptoms described are not consistent with an allergic reaction, so giving diphenhydramine is not the appropriate response.
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