Before administering a newly prescribed dose of terbinafine HCL to a client with a fungal toenail infection, which assessment finding is most important for the nurse to address?
Reported history of alcoholism.
Toenails appear thick and yellow.
Employed as a construction worker.
White blood cell count of 8,500/mm³ (8.5 x 10⁹/L).
The Correct Answer is A
Choice A rationale
Reported history of alcoholism is the most important assessment finding to address before administering terbinafine HCL. Terbinafine is metabolized by the liver, and clients with a history of alcoholism may have impaired liver function, increasing the risk of hepatotoxicity. Monitoring liver function and assessing for signs of liver damage are crucial before starting treatment.
Choice B rationale
Toenails appear thick and yellow is a common symptom of fungal toenail infection, but it is not the most critical assessment finding to address before administering terbinafine HCL. The focus should be on assessing liver function.
Choice C rationale
Employed as a construction worker is not the most critical assessment finding to address before administering terbinafine HCL. While occupational exposure to fungi may be relevant, the primary concern is liver function.
Choice D rationale
White blood cell count of 8,500/mm³ (8.5 x 10⁹/L) is within the normal range and is not the most critical assessment finding to address before administering terbinafine HCL. The primary concern is liver function.
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View Related questions
Correct Answer is C
Explanation
Choice A rationale
Promoting effective swallowing is important for patients with dysphagia, but it is not the primary goal for a client with a sliding hiatal hernia. The main concern with a sliding hiatal hernia is the prevention of gastroesophageal reflux, which can lead to complications such as esophagitis and Barrett’s esophagus.
Choice B rationale
Maintaining intact oral mucosa is crucial for patients with conditions affecting the mouth, such as oral mucositis or infections. However, it is not the primary goal for a client with a sliding hiatal hernia. The focus should be on preventing reflux and managing symptoms.
Choice C rationale
Preventing esophageal reflux is the primary goal for a client with a sliding hiatal hernia. This condition occurs when the stomach slides up into the chest through the diaphragm, leading to gastroesophageal reflux disease (GERD). Nursing actions should aim to reduce reflux symptoms by advising the client to eat smaller meals, avoid lying down after eating, and elevate the head of the bed.
Choice D rationale
Increasing intestinal peristalsis is important for patients with conditions like constipation or ileus. However, it is not the primary goal for a client with a sliding hiatal hernia. The focus should be on preventing reflux and managing symptoms.
Correct Answer is A
Explanation
Choice A rationale
Irregular rapid heart rate (tachycardia) is a serious side effect of albuterol and warrants immediate intervention. Albuterol is a beta-2 agonist that can cause stimulation of beta-1 receptors in the heart, leading to tachycardia and potential arrhythmias.
Choice B rationale
Uncontrollable shaking (tremors) is a common side effect of albuterol due to its stimulation of beta-2 receptors in skeletal muscles. While uncomfortable, it is not typically life-threatening.
Choice C rationale
Increased anxiety can occur with albuterol use due to its stimulant effects on the central nervous system. However, it is not as immediately dangerous as tachycardia.
Choice D rationale
Throat irritation is a minor side effect of albuterol and does not require immediate intervention.