A nurse is preparing to administer epoetin to a client who has anemia due to chemotherapy. Which of the following actions should the nurse plan to take?
Review the client’s Hgb level prior to administration.
Use the Z-track method when administering the medication.
Shake the vial for 30 seconds prior to withdrawing the medication.
Ensure the client is not taking iron supplements while on this medication.
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
A red tag is used to label those who cannot survive without immediate treatment but who have a chance of survival. The child’s respiratory rate of 8/min, unresponsiveness to verbal commands, and groaning to painful stimuli indicate severe injuries that require urgent medical attention. Immediate intervention is necessary to address potential life-threatening conditions.
Choice B Reason:
A yellow tag is assigned to those who require observation and possible later re-triage. Their condition is stable for the moment, and they are not in immediate danger of death. Given the child’s critical condition, a yellow tag would not be appropriate as it suggests the child can wait for treatment, which is not the case here.
Choice C Reason:
A green tag is for the “walking wounded” who will need medical care at some point after more critical injuries have been treated. This tag is not suitable for the child in question, as their condition is far from minor and requires immediate attention.
Choice D Reason:
A black tag is used for the deceased or those whose injuries are so severe that they are not expected to survive despite receiving care. While the child’s condition is critical, they still have a chance of survival with immediate treatment, making a black tag inappropriate.
Correct Answer is B
Explanation
Choice A Reason
Request a prescription for an antibiotic. This intervention is not typically included in the standard care plan for all COPD patients. Antibiotics are generally reserved for cases of acute exacerbations of COPD (AECOPD) with signs of bacterial infection, such as increased dyspnea, increased sputum purulence, and increased sputum volume. Routine use of antibiotics without these signs is not recommended.
Choice B Reason
Educate the client on pursed-lip breathing. This is the correct intervention. Pursed-lip breathing is a technique that helps improve ventilation, release trapped air in the lungs, and reduce the work of breathing. It is particularly beneficial for patients with COPD as it helps them manage shortness of breath and improve their breathing efficiency.
Choice C Reason
Place the client on airborne precautions. This intervention is incorrect. COPD is not an infectious disease that requires airborne precautions. Airborne precautions are used for diseases that are transmitted through the air, such as tuberculosis. COPD management focuses on improving lung function and preventing exacerbations.
Choice D Reason
Initiate oxygen therapy for SpO₂ of 92%. This intervention is partially correct but needs clarification. Oxygen therapy is typically initiated for COPD patients with chronic hypoxemia, usually when SpO₂ is less than 88-90%. An SpO₂ of 92% may not necessarily require oxygen therapy unless the patient is experiencing significant symptoms or has other comorbid conditions.
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