Nokea
A nurse is monitoring for an infusion reaction for a client who is receiving a dose of IV amphotericin B. Which of the following findings should indicate to the nurse that the client is experiencing an acute infusion reaction?
- A. Fever
- B. Dry cough
- C. Hyperglycemia
- D. Pedal edema
Correct Answer: A
Rationale: The correct answer is A: Fever. A fever is a common sign of an acute infusion reaction to IV amphotericin B, indicating a systemic inflammatory response. This reaction may manifest as chills and a high temperature. The other choices (B: Dry cough, C: Hyperglycemia, D: Pedal edema) are less likely to be directly related to an acute infusion reaction with amphotericin B. Dry cough may be associated with respiratory issues, hyperglycemia with diabetes or steroid use, and pedal edema with fluid overload or heart failure. In this scenario, the presence of fever is the most indicative of an acute infusion reaction requiring immediate attention and intervention.
You may also like to solve these questions
A nurse is caring for a client who has a peripheral IV catheter and a prescription for IV fluid replacement. The nurse should cover the insertion site with which of the following types of dressing?
- A. Transparent membrane dressing
- B. Hydrocolloid dressing
- C. Sterile gauze bandage
- D. Adhesive bandage
Correct Answer: A
Rationale: The correct answer is A: Transparent membrane dressing. This type of dressing allows for easy visualization of the IV site, enabling the nurse to monitor for signs of infection or infiltration. It also provides a barrier against external contaminants while maintaining a moist environment conducive to wound healing.
Choice B, hydrocolloid dressing, is not ideal for IV sites as it is more suitable for wounds with moderate exudate. Choice C, sterile gauze bandage, may not allow for easy monitoring of the IV site without removing the dressing. Choice D, adhesive bandage, does not provide adequate protection for an IV site.
A nurse is caring for a client who is taking azathioprine to treat rheumatoid arthritis. Which of the following laboratory values indicates an adverse effect of this medication?
- A. BUN 15 mg/dL
- B. WBC 3,000/mm²
- C. Hct 45%
- D. Platelets 250,000/mm²
Correct Answer: B
Rationale: The correct answer is B: WBC 3,000/mm². Azathioprine is an immunosuppressant medication that can cause bone marrow suppression, leading to a decrease in white blood cell (WBC) count. A low WBC count increases the risk of infections, which is an adverse effect of the medication.
Incorrect choices:
A: BUN 15 mg/dL - Blood urea nitrogen (BUN) is a measure of kidney function and is not directly related to azathioprine's adverse effects.
C: Hct 45% - Hematocrit (Hct) measures the percentage of red blood cells in the blood and is not typically affected by azathioprine.
D: Platelets 250,000/mm² - Platelet count is not commonly impacted by azathioprine and does not indicate an adverse effect of the medication.
A nurse is caring for a client who is taking lithium and reports starting a new exercise program. The nurse should assess the client for which of the following electrolyte imbalances?
- A. Hypomagnesemia
- B. Hypokalemia
- C. Hyponatremia
- D. Hypocalcemia
Correct Answer: C
Rationale: The correct answer is C, Hyponatremia. Lithium can cause the body to retain water, leading to dilution of sodium levels in the blood. This can result in hyponatremia, which can be exacerbated by starting a new exercise program due to increased sweating and potential dehydration. Hypomagnesemia (A), hypokalemia (B), and hypocalcemia (D) are not directly related to lithium use. Hyponatremia is the most relevant electrolyte imbalance to monitor in this scenario.
A nurse is reviewing medication prescriptions for a client. For which of the following entries on the client's medication administration record should the nurse request clarification?
- A. Simvastatin 40 mg PO at bedtime
- B. Morphine 4 mg IV every 4 hr PRN for pain
- C. Levothyroxine 100 mcg PO every morning
- D. Acetaminophen 500 mg every 4 hr PRN for fever
Correct Answer: B
Rationale: The correct answer is B. The nurse should request clarification for Morphine 4 mg IV every 4 hr PRN for pain because the route of administration is not specified. Without the route, there is a risk of error in administering the medication. Choice A is correct as it provides clear instructions for Simvastatin. Choices C and D are also correct as they specify the medication, dosage, route, frequency, and indication.
A nurse is teaching a client's partner how to administer an otic medication to the client. Which of the following statements by the client's partner indicates an understanding of the teaching?
- A. I will have my partner tilt their head back while I am instilling the drops.
- B. I will have my partner lie down on their back while I am instilling the drops.
- C. I will pull the pinna upward and outward prior to instilling the drops,
- D. I will make sure the solution is cool prior to instilling the drops
Correct Answer: C
Rationale: Correct Answer: C: "I will pull the pinna upward and outward prior to instilling the drops."
Rationale: Pulling the pinna upward and outward straightens the ear canal, allowing proper administration of the otic medication. This action helps ensure the drops reach the eardrum effectively. Tilted head or lying down can cause the medication to flow out of the ear. Checking the temperature is not necessary for administering otic medications.