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 D

Explanation

A. Congenital cataracts are present at birth and are relatively rare. In older adults, cataracts are primarily associated with age-related changes rather than congenital factors.
B. While certain medications used to treat asthma, like corticosteroids, can contribute to the development of cataracts, asthma itself is not a direct cause of cataracts. This connection is not strong enough to be considered a common cause.
C. While eye injuries can lead to cataract formation, they are not the most common cause, especially in the older adult population. Most cataracts develop due to age-related changes rather than trauma.
D. The most prevalent cause of cataracts, especially in older adults, is aging. As people get older, changes in the lens of the eye can lead to clouding, resulting in cataracts. Factors like UV exposure, smoking, and certain medical conditions may also contribute, but aging is the primary and most common factor.

A. Lesions in the scalp that extend to the hairline or neck. B. Circular lesion with raised edges and central clearing and itching C. White sacs attached to the hair shafts in the occipital area D. Maculopapular lesions behind the ears.

Correct Answer is C

Explanation

A. While scratching due to lice can lead to irritation and lesions, this finding is not specific to pediculosis capitis. Lesions extending to the hairline or neck could be caused by various conditions, such as eczema or dermatitis, rather than lice infestation.
B. This description is more characteristic of tinea capitis (scalp ringworm) rather than pediculosis capitis. Tinea capitis presents as circular patches with raised edges and may cause itching, but it is not caused by lice.
C. In cases of pediculosis capitis, the white sacs refer to nits (lice eggs), which are commonly found attached to hair shafts, especially around the occipital area (back of the head). Nits are oval and may be mistaken for dandruff but are firmly attached to the hair.
D. While maculopapular lesions can be a result of scratching, they are not a typical finding in pediculosis capitis. Such lesions might indicate another skin condition or an allergic reaction rather than an infestation of lice.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult patient asks the nurse what caused his cataract. The nurse's response is based on which information?

Correct Answer is D

Explanation

The school nurse is conducting pediculosis capitis checks. A child with a positive head check would have which finding?

Correct Answer is C

Explanation

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