A hospitalized patient is receiving an antiviral drug to treat cytomegalovirus. What is the nurse's priority action after administering the antiviral drug?
A) Monitor vital signs every hour.
B) Decrease fluid intake.
C) Keep side rails up.
D) Encourage the patient to ambulate 10 minutes after each dose.
C
Feedback:
Antiviral drugs for herpes and cytomegalovirus can cause confusion, dizziness, and other central nervous system (CNS) effects. Side rails should be up after administration to protect the patient from injury until risk for these adverse effects is lowered because not every patient will experience these effects. The patient should not be encouraged to walk after each dose because of the risk of falls if adverse effects occur. Fluid intake should be slightly increased to help decrease risk of nephrotoxicity. Vital signs should be monitored, but it would not be necessary to take them every hour unless serious adverse effects occur.
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