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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.
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A nurse is caring for a client who has a prescription for amoxicillin. Which of the following findings indicates the client is experiencing an allergic reaction?
- A. Laryngeal edema
- B. Nausea
- C. Cardiac dysrhythmia
- D. Insomnia
Correct Answer: A
Rationale: The correct answer is A: Laryngeal edema. Laryngeal edema is a severe symptom of an allergic reaction, indicating potential anaphylaxis, a life-threatening condition. It can lead to airway obstruction and respiratory distress. Nausea (B) is a common side effect of amoxicillin and does not necessarily indicate an allergic reaction. Cardiac dysrhythmia (C) and insomnia (D) are not typical manifestations of an allergic reaction to amoxicillin. A systematic approach to identifying allergic reactions is crucial in ensuring prompt intervention and preventing further complications.
A nurse is reviewing the laboratory results of a client who is taking amitriptyline. Which of the following laboratory values should the nurse report to the provider?
- A. Potassium 4.2 mEq/L
- B. Total bilirubin 1.5 mg/dL
- C. WBC count 5,000/mm²
- D. Hct 44%
Correct Answer: B
Rationale: The correct answer is B: Total bilirubin 1.5 mg/dL. Amitriptyline can affect liver function, leading to increased levels of bilirubin. Elevated bilirubin levels may indicate hepatotoxicity, which can be a serious side effect requiring medical intervention.
A: Potassium level within the normal range is not typically affected by amitriptyline.
C: WBC count within the normal range is not directly influenced by amitriptyline.
D: Hct within the normal range is not typically impacted by amitriptyline.
A nurse is teaching a client who has a prescription for ferrous gluconate. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should take this medication with 8 ounces of milk.
- B. I should take an antacid with this medication to prevent stomach upset.
- C. I should notify my provider if my stools turn black
- D. I should stay upright for at least 15 minutes after taking this medication
Correct Answer: C
Rationale: Correct Answer: C. "I should notify my provider if my stools turn black."
Rationale: Ferrous gluconate is an iron supplement that may cause dark or black stools, indicating the medication is being absorbed properly. This can be a normal side effect and does not necessarily indicate a problem. However, it is important for the client to notify their healthcare provider to monitor their response to the medication. This statement shows the client understands the potential side effects and the importance of communication with their provider.
Incorrect Answers:
A: Taking ferrous gluconate with milk can decrease its absorption due to the calcium in milk.
B: Antacids can decrease the absorption of iron, so taking them together is not recommended.
D: Staying upright after taking ferrous gluconate is not necessary for this medication.
A nurse is caring for a client who requires a re-insertion of a short peripheral venous catheter. In which of the following locations should the nurse place the catheter?
- A. A vein that feels hard to the touch
- B. A vein in the client's dominant arm
- C. A vein proximal to the previous site
- D. A vein on the client's wrist
Correct Answer: C
Rationale: The correct answer is C: A vein proximal to the previous site. This location is preferred to prevent complications like phlebitis. Proximal insertion reduces the risk of infection from the previous site and allows for better vein integrity. Option A is incorrect because a hard vein may indicate thrombosis. Option B should be avoided in the dominant arm to prevent disruption of daily activities. Option D on the wrist is not ideal due to the risk of movement-related dislodgement.
A nurse is preparing to administer acyclovir 10 mg/kg IV to a client who weighs 132 lbs. Available is acyclovir IV injectable solution 30 mg/mL. How many mL should the nurse administer?
- A. 20 mL
Correct Answer: A
Rationale: To calculate the dose of acyclovir for the client, first convert the weight to kg (132 lbs / 2.2 = 60 kg). Then, calculate the dose: 10 mg/kg x 60 kg = 600 mg. Next, determine the volume needed: 600 mg / 30 mg/mL = 20 mL. Therefore, the correct answer is A: 20 mL. Other choices are incorrect as they do not align with the calculations based on the client's weight and the concentration of the IV solution.