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Questions 158

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Question 1 of 5

A client has viral encephalitis and has been prescribed IV acyclovir (Zovirax). What nursing interventions should be used when administering the drug?

Correct Answer: A, B, C, E

Rationale: Acyclovir requires slow infusion (
A) to prevent phlebitis, adequate hydration (
B) to reduce nephrotoxicity, monitoring for neurotoxicity (
C), and caution in renal insufficiency (E). Heart rate (
D) is unrelated.

Question 2 of 5

A client is admitted to the hospital with diabetic ketoacidosis. The emergency room nurse should anticipate the administration of:

Correct Answer: B

Rationale: Regular insulin is rapid acting and indicated in an emergency situation.

Question 3 of 5

A client is resting comfortably after delivering her first child. When assessing her pulse rate, the nurse would recognize the following finding to be typical:

Correct Answer: D

Rationale: Puerperal bradycardia with rates of 50-70 bpm commonly occurs during the first 6-10 days of the postpartal period. It may be related to decreased cardiac strain, decreased blood volume, contraction of the uterus, and increased stroke volume.

Question 4 of 5

Which of the following serum laboratory values would the nurse monitor during gentamicin therapy?

Correct Answer: A

Rationale: A common side effect of gentamicin is nephrotoxicity. The serum laboratory test that best reflects kidney function is serum creatinine.

Question 5 of 5

The nurse is assessing breath sounds in a bronchovesicular client. She should expect that:

Correct Answer: D

Rationale: Inspiration is normally longer in vesicular areas. High-pitched sounds are normal in bronchial area. Muffled sounds are considered abnormal. Inspiration and expiration are equal normally in this area, and sounds are medium pitched.

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