A nurse is monitoring a client who has a traumatic brain injury and a ventriculostomy drain. The nurse should report which of the following findings as a complication of this therapeutic procedure? (Select all that apply.)

Choice A Reason

Review the client’s Hgb level prior to administration. This is the correct action. Monitoring hemoglobin (Hgb) levels is crucial before administering epoetin because it helps determine the appropriate dosage and ensures the treatment is safe and effective. Epoetin is used to stimulate red blood cell production, and administering it without checking Hgb levels can lead to complications such as hypertension or thromboembolic events if the Hgb level is too high.

Choice B Reason

Use the Z-track method when administering the medication. This statement is incorrect. The Z-track method is used for intramuscular injections to prevent medication from leaking into subcutaneous tissues. Epoetin is typically administered subcutaneously or intravenously, not intramuscularly, so the Z-track method is not applicable.

Choice C Reason

Shake the vial for 30 seconds prior to withdrawing the medication. This statement is incorrect. Shaking the vial of epoetin can damage the protein structure of the medication, rendering it ineffective. The vial should be gently swirled if necessary, but not shaken.

Choice D Reason

Ensure the client is not taking iron supplements while on this medication. This statement is incorrect. Iron supplements are often necessary when administering epoetin because iron is required for the production of hemoglobin. Ensuring adequate iron levels helps maximize the effectiveness of epoetin therapy.

Choice A Reason:

Respiratory acidosis is characterized by a low pH (below 7.35) and an elevated PaCO₂ (above 45 mm Hg). This condition occurs when there is an accumulation of carbon dioxide in the blood due to hypoventilation or impaired lung function. In this case, the client’s pH is elevated, and PaCO₂ is low, which does not align with respiratory acidosis.

Choice B Reason:

Respiratory alkalosis is indicated by a high pH (above 7.45) and a low PaCO₂ (below 35 mm Hg). This condition results from hyperventilation, which causes excessive exhalation of carbon dioxide. The client’s ABG results show a pH of 7.50 and a PaCO₂ of 29 mm Hg, consistent with respiratory alkalosis.

Choice C Reason:

Metabolic acidosis is characterized by a low pH (below 7.35) and a low HCO₃ (below 21 mEq/L). This condition occurs due to an accumulation of acids or a loss of bicarbonate in the body. The client’s pH is elevated, and HCO₃ is within the normal range, which does not indicate metabolic acidosis.

Choice D Reason:

Metabolic alkalosis is indicated by a high pH (above 7.45) and a high HCO₃ (above 28 mEq/L). This condition results from an excess of bicarbonate or a loss of acids. The client’s pH is elevated, but HCO₃ is within the normal range, which does not support a diagnosis of metabolic alkalosis.