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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

a) An elevated temperature could indicate an infection, which is a serious concern in a client taking steroids, as steroids can suppress the immune system. This finding should be reported immediately.

b) Blood pressure within this range is generally acceptable and may not be a cause for immediate concern.

c) A glucose level of 128 mg/dl is within a reasonable range and may not require immediate reporting unless there are other concerning factors.

d) A heart rate of 102 beats per minute is generally within an acceptable range and may not be an immediate cause for concern in the absence of other symptoms.

A. "I can rotate acetaminophen with ibuprofen if needed for pain control, so I don't take too much of either one." B. "If I still have pain 10 minutes after taking 1000 mg of acetaminophen, I should take two of oxycodone-acetaminophen." C. "Taking more than 4000 mg of acetaminophen in a day can cause liver problems." D. "Taking acetaminophen often could mask any infection-related fevers I might have."

Correct Answer is D

Explanation

a) The statement about rotating acetaminophen with ibuprofen for pain control demonstrates an understanding of the principles of multimodal pain management and is appropriate.

b) The statement about taking two oxycodone-acetaminophen tablets if pain persists after a certain time frame is appropriate and reflects awareness of appropriate pain management strategies.

c) The statement about the maximum daily dose of acetaminophen and its potential to cause liver problems is accurate and indicates good knowledge.

d) The statement about acetaminophen masking infection-related fevers is incorrect. While acetaminophen can reduce fever, it does not mask the presence of an infection. This statement indicates a need for further teaching.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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