Which nursing intervention is most critical during the administration of acyclovir?

Utilize an incentive spirometer

Encourage a high-carbohydrate diet

Limit the client's activity

Encourage fluids

Answer and Explanation

The Correct Answer is D

A.   While using an incentive spirometer is important in promoting lung expansion and preventing respiratory complications, it is not directly related to the administration of acyclovir. This intervention is typically more relevant for patients at risk of respiratory issues.
B.   A high-carbohydrate diet is not a specific recommendation related to acyclovir administration. While nutrition is important for overall health, this intervention does not address the key concerns associated with the use of acyclovir.
C.   While activity levels may need to be monitored based on the patient's overall condition, limiting activity is not a primary concern with acyclovir. The medication itself does not usually require significant restrictions on physical activity unless the patient has other conditions that warrant it.
D.   Acyclovir can be nephrotoxic, especially when given intravenously, and maintaining adequate hydration helps prevent kidney damage. Encouraging fluids ensures that the kidneys can effectively excrete the medication and reduces the risk of crystallization in the renal tubules.

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Correct Answer is A

Explanation

A. Primary hypertension, also known as essential hypertension, is characterized by high blood pressure that does not have a known secondary cause. It accounts for the majority of hypertension cases and is thought to result from a combination of genetic, environmental, and lifestyle factors.
B. While treatment is important for all forms of hypertension to prevent complications, this statement is somewhat misleading. The term "essential" in primary hypertension refers to the lack of a specific identifiable cause, not that it is necessarily more critical to treat than other forms of hypertension.
C. This definition describes secondary hypertension, not primary hypertension. Secondary hypertension results from an identifiable underlying condition, such as kidney disease or hormonal disorders.
D. Primary hypertension can vary in severity, but it is not exclusively severe or life-threatening. While uncontrolled hypertension can lead to serious complications, primary hypertension itself does not automatically imply a critical state.

A. Cyanosis B. Restlessness C. Increased respirations D. Hypertension

Correct Answer is B

Explanation

A. Cyanosis is a late sign of hypoxia, occurring when oxygen saturation is significantly low. It's often visible in the mucous membranes and skin.
B. Restlessness is often one of the earliest signs of hypoxia. As oxygen levels decrease, the brain becomes deprived of oxygen, leading to changes in mental status, including restlessness, confusion, and agitation.
C. Increased respirations (tachypnea) can be a sign of hypoxia, but it's often a later response as the body attempts to compensate for decreased oxygen levels.
D. Hypertension is not a typical sign of hypoxia. In fact, severe hypoxia can lead to hypotension as blood pressure decreases.

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Which nursing intervention is most critical during the administration of acyclovir?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A student nurse asks what "primary hypertension" is. What response by the registered nurse is best?

Correct Answer is A

Explanation

The nurse is aware the early indicator of hypoxia in the unconscious client is:

Correct Answer is B

Explanation

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