A nurse is monitoring for an infusion reaction for a client who is receiving a dose of IV amphotericin B. Which of the following findings should indicate to the nurse that the client is experiencing an acute infusion reaction?
Pedal edema.
Fever.
Dry cough.
Hyperglycemia.
The Correct Answer is B
This is because fever is a common sign of an acute infusion reaction that can occur when receiving IV amphotericin B. An acute infusion reaction is caused by the release of pro-inflammatory cytokines from the fungal cell wall disruption by amphotericin B. It usually occurs within the first hour of infusion and can be prevented by administering pre-medications such as antipyretics, antihistamines, or corticosteroids.
Choice A. Pedal edema is wrong because it is not a typical sign of an acute infusion reaction.
Pedal edema may indicate fluid overload, heart failure, or renal impairment, which are not directly related to amphotericin B infusion.
Choice C. Dry cough is wrong because it is not a typical sign of an acute infusion reaction.
Dry cough may indicate an allergic reaction, pulmonary infection, or interstitial lung disease, which are not directly related to amphotericin B infusion. Choice D. Hyperglycemia is wrong because it is not a typical sign of an acute infusion reaction.
Hyperglycemia may indicate diabetes mellitus, steroid use, or stress response, which are not directly related to amphotericin B infusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Albumin is a protein that helps maintain fluid balance in the body by drawing water into the blood vessels. Albumin infusion can increase the blood volume and blood pressure in patients who are in shock due to fluid loss or sepsis.
Choice A is wrong because albumin infusion does not decrease protein levels in the body.
Albumin is a protein itself and adding it to the blood increases the protein concentration.
Choice C is wrong because oxygen saturation of 96% is normal and does not indicate any improvement or deterioration in the patient’s condition.
Choice D is wrong because PaCO2 of 30 mm Hg is low and indicates respiratory alkalosis, which can be caused by hyperventilation, fever, or anxiety. Albumin infusion does not affect PaCO2 levels directly.
Correct Answer is D
Explanation
This is because swelling of the feet can be a sign of lithium toxicity, which is a serious condition that can occur when the level of lithium in the blood is too high. Lithium toxicity can cause confusion, irregular heartbeat, muscle weakness, and kidney problems. Therefore, the client should report any signs of lithium toxicity to their provider as soon as possible.
Choice A is wrong because limiting foods containing tyramine is not necessary for clients taking lithium. Tyramine is a substance found in some foods that can interact with certain antidepressants called monoamine oxidase inhibitors (MAOIs), but not with lithium.
Choice B is wrong because decreasing the daily sodium intake can actually increase the risk of lithium toxicity.
Sodium helps to regulate the amount of lithium in the body, so if the sodium level is low, the lithium level can rise too high.
The client should maintain a normal sodium intake and drink enough fluids while taking lithium.
Choice C is wrong because taking this medication 2 hours before a meal is not required for clients taking lithium.
Lithium can be taken with or without food, but it should be taken at the same time each day to keep a steady level in the blood.
Taking lithium 2 hours before a meal may cause stomach upset, which is a common side effect of lithium.
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