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 B
Explanation
Choice A Reason
4g sodium diet. While reducing sodium intake is important for managing chronic kidney disease (CKD), a specific 4g sodium diet is not typically prescribed. Instead, patients are generally advised to limit sodium intake to less than 2,300 milligrams per day to help control blood pressure and reduce fluid retention.
Choice B Reason
Potassium-restricted diet. This is the correct intervention. Patients with CKD often have difficulty excreting potassium, leading to hyperkalemia, which can be dangerous. Therefore, a potassium-restricted diet is commonly recommended to maintain normal serum potassium levels.
Choice C Reason
High-phosphorus diet. This statement is incorrect. Patients with CKD are usually advised to limit phosphorus intake because their kidneys cannot effectively excrete phosphorus, leading to hyperphosphatemia. High phosphorus levels can cause bone and cardiovascular problems.
Choice D Reason
High-protein diet. This statement is incorrect. While protein is essential, excessive protein intake can increase the workload on the kidneys. Patients with CKD are often advised to follow a moderate protein diet to reduce the production of waste products that the kidneys need to filter.
Correct Answer is ["A","B","C"]
Explanation
Choice A Reason:
Infection is a significant complication of a ventriculostomy drain. The presence of a foreign object in the brain increases the risk of infections such as meningitis or ventriculitis. Signs of infection can include fever, redness, swelling at the insertion site, and changes in mental status.
Choice B Reason:
Vomiting can be a sign of increased intracranial pressure (ICP), which is a serious complication in clients with a traumatic brain injury and a ventriculostomy drain. Increased ICP can lead to further brain injury and requires immediate medical attention.
Choice C Reason:
Widening pulse pressure (the difference between systolic and diastolic blood pressure) can indicate increased intracranial pressure. This is a critical finding that should be reported immediately as it can signify worsening brain injury or other complications.
Choice D Reason:
Equal and reactive pupils are generally a normal finding and do not indicate a complication. This suggests that the brainstem is functioning properly and there is no significant increase in intracranial pressure affecting the cranial nerves.
Choice E Reason:
An intracranial pressure reading of 10 mm Hg is within the normal range (typically 7-15 mm Hg for adults). Therefore, this finding does not indicate a complication and does not require immediate reporting.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.