A nurse is caring for a client who is having difficulty voiding following surgery. The nurse notes palpable bladder distention. Which of the following medications should the nurse anticipate administering to the client?
Furosemide
Lorazepam
Bethanechol
Atropine
The Correct Answer is C
Rationale:
A. Furosemide is a diuretic that promotes urine production but is not indicated for treating bladder distention or urinary retention post-surgery.
B. Lorazepam is an anxiolytic medication and does not address urinary retention or bladder distention.
C. Bethanechol is a cholinergic agent that stimulates bladder contraction and is used to treat urinary retention. It helps to facilitate voiding in clients who have difficulty.
D. Atropine is an anticholinergic medication that can actually inhibit bladder contraction, making it inappropriate for this situation.
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Correct Answer is C
Explanation
Rationale:
A. Magnesium 2.5 mEq/L: A magnesium level slightly above the normal range does not indicate an immediate need to discontinue clozapine, as this level is not related to the adverse effects of the drug.
B. Potassium 5.4 mEq/L: While elevated potassium levels can pose a health risk, this is not a direct indicator to discontinue clozapine. Potassium levels can be managed with other interventions.
C. WBC 2,500/mm³: Clozapine carries a risk of agranulocytosis, a condition where the white blood cell (WBC) count becomes dangerously low, leading to severe infection risk. A WBC count of 2,500/mm³ is below the normal range and indicates the need to discontinue clozapine immediately.
D. Sodium 134 mEq/L: A slightly low sodium level is not typically related to clozapine use and does not warrant discontinuation of the medication.
Correct Answer is C
Explanation
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.