A nurse is reviewing the lab work of a client on a medical-surgical unit who has a new prescription for captopril. Which of the following laboratory values should the nurse identify as the priority to monitor?
Alanine aminotransferase
Thyroid-stimulating hormone
Potassium
Magnesium
The Correct Answer is C
Rationale:
A. Monitoring alanine aminotransferase is important for liver function, but it is not the priority for a client on captopril.
B. Thyroid-stimulating hormone is not directly impacted by captopril and is not the priority lab value to monitor in this context.
C. Potassium is the priority laboratory value to monitor because captopril, an ACE inhibitor, can lead to hyperkalemia (elevated potassium levels), which can cause serious cardiac complications.
D. While magnesium levels are important to monitor, they are not specifically related to captopril therapy as potassium levels are.
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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.
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.