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 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.
Correct Answer is C
Explanation
Rationale:
A. Delaying the incident report until the end of the current shift can compromise the timely documentation of the error and any necessary interventions that may arise.
B. While it's important to notify risk management, the priority should be to document the incident immediately after assessing the client to ensure a complete record of the error.
C. Completing the incident report as soon as the assessment is complete is the most appropriate action, allowing for prompt documentation of the error and any potential effects on patient care.
D. Informing the previous nurse is necessary for communication, but it should not delay the completion of the incident report, which is crucial for tracking errors and improving safety protocols.