A nurse is planning care for a client who has a prescription for erythromycin lactobionate IV bolus.
Which of the following actions should the nurse include in the plan of care?
Monitor the client for hearing loss.
Implement a high-fiber diet to prevent constipation.
Administer the medication over 10 min.
Reconstitute the medication with a 5% dextrose solution.
The Correct Answer is A
The nurse should monitor the client for hearing loss because it is a potential adverse effect of erythromycin.
Choice B is wrong because a high-fiber diet to prevent constipation is not mentioned as a necessary action when administering erythromycin lactobionate IV bolus.
Choice C is wrong because erythromycin lactobionate IV bolus should not be administered over 10 min; bolus injection (IV push) is contraindicated.
Choice D is wrong because erythromycin lactobionate should not be reconstituted with a 5% dextrose solution; it should be reconstituted with sterile water for injection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Anaphylaxis is a severe, potentially life-threatening allergic reaction that can occur within seconds or minutes of exposure to an allergen, such as penicillin.
One of the symptoms of anaphylaxis is wheezing, which is caused by the constriction of the airways and a swollen tongue or throat.
Choice A is wrong because hypertonia (increased muscle tone) is not a known symptom of anaphylaxis.
Choice C is wrong because urinary retention (inability to completely empty the bladder) is not a known symptom of anaphylaxis.
Choice D is wrong because increased blood pressure is not a known symptom of anaphylaxis; in fact, anaphylaxis can cause a sudden drop in blood pressure.
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale:
Documenting the administration of the medication is crucial for maintaining accurate records and ensuring accountability. However, it is not the first action to take. The priority is to ensure the correct patient receives the correct medication.
Choice B rationale:
Identifying the client using two identifiers is the first and most critical step. This action ensures that the right patient receives the right medication, thereby minimizing the risk of medication errors.
Choice C rationale:
Comparing the amount of medication available to the inventory record is important for maintaining accurate inventory and preventing misuse or theft of controlled substances. However, this is not the first step in the process of administering medication to a patient in pain.
Choice D rationale:
Removing the medication from the medication dispensing cabinet is part of the process, but it should only be done after the patient has been properly identified to avoid any potential errors.
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