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
The nurse should plan to take the following action:
A) Mix the medications with a semisolid food for the client.
Mixing the medications with a semisolid food, such as applesauce or pudding, can make it easier for an older adult client with dysphagia to swallow the medications safely. It helps in reducing the risk of choking and aspiration. This approach is typically used for clients who have difficulty swallowing pills.
Options B, C, and D are not recommended for a client with dysphagia:
B) Administering more than one pill at a time can increase the risk of choking and aspiration, which should be avoided.
C) Placing medications on the back of the client's tongue can also lead to difficulty swallowing and an increased risk of aspiration.
D) Tilting the client's head back when administering medications is not recommended as it can lead to aspiration. The head should be kept in a neutral position to support safe swallowing.
Correct Answer is C
Explanation
Phenytoin is an anticonvulsant medication that can cause hypotension as an adverse effect when administered intravenously. The nurse should monitor the client’s blood pressure and heart rate during and after the infusion.
Choice Ais wrong because phenytoin does not cause bradycardia. Bradycardia is a slow heart rate that can result from beta blockers, calcium channel blockers, or digoxin toxicity.
Choice B is wrong because red man syndrome is an adverse reaction to vancomycin, not phenytoin.
Red man syndrome is characterized by flushing, itching, and rash on the face, neck, and upper torso.
Choice Dis wrong because phenytoin does not cause hypoglycemia. Hypoglycemia is a low blood glucose level that can result from insulin overdose, excessive exercise, or inadequate food intake.
Normal ranges for blood pressure are 90/60 mm Hg to 120/80 mm Hg. Normal ranges for heart rate are 60 to 100 beats per minute. Normal ranges for blood glucose are 70 to 110 mg/dL.
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