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.
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Explanation
Rationale:
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B. Furosemide: This diuretic is unlikely to cause chest pain directly; however, it may lead to electrolyte imbalances that can indirectly affect cardiac function.
C. Digoxin: While digoxin has several potential side effects, chest pain is not commonly recognized as a direct adverse effect of this medication.
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Correct Answer is A
Explanation
Rationale:
A. Nitrofurantoin can cause brown-colored urine due to its pigment, and clients should be informed to report this as a common side effect and not a cause for alarm.
B. Nitrofurantoin is an antibiotic used to treat urinary tract infections and does not provide relief for peripheral nerve pain.
C. Nitrofurantoin should not be crushed, as it can affect the medication's absorption and effectiveness.
D. A cough is not a typical side effect of nitrofurantoin; however, if the client develops a cough, it could be a sign of a serious side effect, and they should notify the provider.