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Questions 149

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Question 1 of 5

A client with AIDS is taking Zovirax (acyclovir). Which nursing intervention is most critical during the administration of acyclovir?

Correct Answer: D

Rationale: Acyclovir can cause nephrotoxicity, so encouraging fluids is critical to prevent kidney damage.

Question 2 of 5

A client is hospitalized with signs of transplant rejection following a recent renal transplant. Assessment of the client would be expected to reveal:

Correct Answer: D

Rationale: Rising blood pressure is a sign of renal transplant rejection due to impaired kidney function and fluid retention.

Question 3 of 5

A client with increased intracranial pressure is placed on mechanical ventilation with hyperventilation. The nurse knows that the purpose of the hyperventilation is to:

Correct Answer: B

Rationale: Hyperventilation reduces PaCO2, causing vasoconstriction and decreasing cerebral blood flow to reduce intracranial pressure.

Question 4 of 5

The nurse is teaching a client on the proper technique to use an inhaler with a spacer for asthma management. Which action by the client would require intervention by the nurse?

Correct Answer: B

Rationale: Placing the inhaler over the tongue obstructs the airway; lips should seal around the mouthpiece with the tongue underneath. Other actions are correct.

Question 5 of 5

Heparin has been ordered for a client with pulmonary embolis. Which statement, if made by the graduate nurse, indicates a lack of understanding of the medication?

Correct Answer: D

Rationale: Aspirating during heparin injection is incorrect, as it increases the risk of hematoma formation in subcutaneous administration.

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