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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Correct Answer is D
Explanation
Rationale:
A. Acetylcysteine is not indicated for gastrointestinal bleeding; other treatments are used for that condition.
B. Acute bronchospasm is treated with bronchodilators rather than acetylcysteine.
C. Morphine toxicity requires other interventions, such as opioid antagonists (e.g., naloxone), and acetylcysteine is not effective in this case.
D. Acetylcysteine is specifically indicated for acetaminophen toxicity as it acts as an antidote, replenishing glutathione stores and preventing liver damage from toxic metabolites.
Correct Answer is B
Explanation
Rationale:
A. "Remove the patch for two to four hours daily.": This is incorrect because transdermal nitroglycerin patches should be worn continuously for 24 hours, with a scheduled time to remove them (usually overnight) to prevent tolerance.
B. "Apply a new patch each day after waking up.": This instruction is correct; clients should apply a new patch daily to ensure continuous therapeutic effects while also allowing a break to reduce tolerance.
C. "Cover the patch with plastic wrap.": This is incorrect; covering the patch with plastic wrap can alter the absorption of the medication and is not necessary.
D. "Replace the existing patch with a new patch as soon as anginal pain begins.": This is incorrect; clients should not replace the patch immediately for angina. Instead, they should use sublingual nitroglycerin for immediate relief and follow the prescribed patch schedule.