A nurse is caring for a client who has a systemic fungal infection and is receiving IV amphotericin B deoxycholate. During previous infusions, the client developed a fever and chills. Which of the following actions should the nurse take?
Apply a warming blanket prior to administration.
Infuse the medication over 1 hr.
Administer diphenhydramine prior to administration.
Monitor vital signs once per hour following administration.
The Correct Answer is C
Rationale:
A. Applying a warming blanket is not appropriate, as it may exacerbate the client's reaction to the infusion and is not a standard pre-medication strategy.
B. Infusing amphotericin B deoxycholate over 1 hour is too rapid; it is typically infused over 2-6 hours to minimize adverse effects.
C. Administering diphenhydramine prior to the administration of amphotericin B can help prevent or alleviate infusion-related reactions such as fever and chills, which the client experienced during previous infusions.
D. Monitoring vital signs once per hour following administration is insufficient; vital signs should be monitored more frequently during and immediately after the infusion to promptly detect and address any adverse reactions.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is A
Explanation
Rationale:
A. Increase fluids while taking the medication: Amitriptyline is a tricyclic antidepressant that can cause anticholinergic side effects such as dry mouth and constipation. Increasing fluid intake helps to mitigate these effects and prevent dehydration and constipation.
B. Expect an elevation in blood pressure with initial doses of the medication: Amitriptyline can cause orthostatic hypotension rather than elevated blood pressure. Clients should be informed about the risk of dizziness or fainting.
C. Stop the medication immediately if urine becomes orange in color: Orange urine is not a common side effect of amitriptyline. Clients should not stop the medication without consulting their provider.
D. Take the medication in the morning: Amitriptyline has sedative effects and is typically taken at night to help manage sleep disturbances and reduce daytime drowsiness.
Correct Answer is B
Explanation
Rationale:
A. A heart rate of 105/min is slightly elevated, but it does not require immediate intervention unless the client is symptomatic or has other concerning signs.
B. Infiltration of the peripheral IV requires immediate intervention, as it can lead to tissue damage and prevent the medication from being effectively delivered. The nurse should stop the infusion, assess the site, and take appropriate action.
C. Increased blood pressure is a common effect of dopamine administration and does not necessarily require urgent intervention unless it becomes critically high or is associated with other adverse symptoms.
D. Occasional PVCs can occur during dopamine infusion and can be monitored unless they become frequent or symptomatic; they typically do not require immediate intervention.