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 A
Explanation
This is because the umbilicus is a potential site of infection and should be avoided when administering subcutaneous heparin.
Choice B is wrong because massaging the site after administering the medication can cause bruising and hematoma formation.
Choice C is wrong because a 21-gauge needle is too large for subcutaneous injection and can cause tissue trauma and bleeding.
A smaller needle, such as 25- or 27-gauge, should be used.
Choice D is wrong because aspirating before injecting the medication can increase the risk of hematoma formation and is not recommended for subcutaneous heparin.
Correct Answer is A
Explanation
Epinephrine (adrenaline) is the first-line treatment for anaphylaxis, a severe and potentially life-threatening allergic reaction. Epinephrine works by reducing the body’s allergic response and improving the breathing and circulation of the client. Epinephrine should be given as soon as possible after the onset of anaphylaxis symptoms, using an auto-injector device if available.
Choice B is wrong because replacing the infusion with 0.9% sodium chloride (normal saline) is not enough to treat anaphylaxis. Normal saline can help maintain the blood pressure and hydration of the client, but it does not reverse the allergic reaction or improve the breathing of the client. Normal saline can be given after epinephrine, but not before or instead of it.
Choice C is wrong because giving diphenhydramine IM is not enough to treat anaphylaxis. Diphenhydramine is an antihistamine that can help relieve some of the symptoms of anaphylaxis, such as itching and hives, but it works too slowly and does not address the more serious effects of anaphylaxis on the breathing and circulation of the client. Diphenhydramine can be given after epinephrine, but not before or instead of it.
Choice D is wrong because elevating the client's legs and feet is not enough to treat anaphylaxis. Elevating the legs and feet can help increase the blood flow to the vital organs, but it does not reverse the allergic reaction or improve the breathing of the client. Elevating the legs and feet can be done after epinephrine, but not before or instead of it.
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