Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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?
A. Pedal edema.
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.
B. Fever.
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.
C. Dry cough.
Dry cough may indicate an allergic reaction, pulmonary infection, or interstitial lung disease, which are not directly related to amphotericin B infusion.
D. Hyperglycemia.
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.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Pharmacology 2019 Proctored Exam. Take the full exam now
Full Explanation
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.
Similar Questions
A nurse is mixing regular insulin and NPH insulin in the same syringe prior to administering it to a client who has diabetes mellitus.
Which of the following actions should the nurse take first?
A. Inject air into the NPH vial.
Injecting air into the NPH vial first helps to equalize the pressure in the vial, making it easier to withdraw the insulin later. This step is done first to avoid contaminating the regular insulin vial with NPH insulin.
B. Withdraw the NPH insulin from the vial.
Finally, the nurse withdraws the NPH insulin. Since the regular insulin has already been drawn up, there is no risk of contaminating the regular insulin with NPH insulin. This is the last step.
C. Withdraw the regular insulin from the vial.
Choice C is wrong because withdrawing the regular insulin from the vial first without injecting air into it would create a vacuum in the vial and make it harder to withdraw the correct dose of insulin.
D. Inject air into the regular insulin vial.
After injecting air into the NPH vial, the nurse should inject air into the regular insulin vial. This also helps to equalize the pressure and makes it easier to withdraw the insulin.
Full Explanation
The correct sequence for mixing regular insulin and NPH insulin in the same syringe is important to ensure proper dosing. The nurse should follow these steps:
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Inject air into the NPH (intermediate-acting) insulin vial: Injecting air into the NPH vial first helps to equalize the pressure in the vial, making it easier to withdraw the insulin later. This step is done first to avoid contaminating the regular insulin vial with NPH insulin.
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Inject air into the regular insulin vial: Next, inject an amount of air equal to the intended regular insulin dose into the regular insulin vial.This also helps to equalize the pressure and makes it easier to withdraw the insulin.
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Withdraw the regular insulin from the vial : The nurse should withdraw the regular insulin first because it is clear and not contaminated. This prevents any NPH insulin from mixing into the regular insulin vial.
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Withdraw the regular insulin from the vial: Finally, the nurse withdraws the NPH insulin. Since the regular insulin has already been drawn up, there is no risk of contaminating the regular insulin with NPH insulin.
This sequence ensures that you don't contaminate the vials, and you accurately withdraw the appropriate doses of each insulin type.
A nurse is teaching a newly licensed nurse about medication reconciliation. The nurse should instruct the newly licensed nurse to perform medication reconciliation for which of the following clients?
A. A client who has a referral for social services.
Choice A is wrong because a referral for social services does not involve a change in the client’s medications or care setting.
B. A client who is transported to radiology.
Choice B is wrong because a transport to radiology is a temporary and short term movement that does not require medication reconciliation.
C. A client who is transferred to a step-down unit.
Medication reconciliation is the process of creating the most accurate list possible of all medications a client is taking and comparing that list against the physician’s orders at every transition of care. A client who is transferred to a step-down unit is at risk of medication errors due to changes in the level of care and the prescribing providers. Therefore, medication reconciliation should be performed for this client to prevent adverse drug events.
D. A client who has a consultation for physical therapy.
Choice D is wrong because a consultation for physical therapy does not affect the client’s medication regimen or orders.
Full Explanation
Medication reconciliation is the process of creating the most accurate list possible of all medications a client is taking and comparing that list against the physician’s orders at every transition of care. A client who is transferred to a step-down unit is at risk of medication errors due to changes in the level of care and the prescribing providers. Therefore, medication reconciliation should be performed for this client to prevent adverse drug events.
Choice A is wrong because a referral for social services does not involve a change in the client’s medications or care setting.
Choice B is wrong because transport to radiology is a temporary and short-term movement that does not require medication reconciliation.
Choice D is wrong because a consultation for physical therapy does not affect the client’s medication regimen or orders.
A nurse is caring for a client who is taking sertraline and reports a desire to begin taking supplements.
Which of the following supplements should the nurse advise the client to avoid?
A. St. John’s Wort.
The nurse should advise the client to avoid taking St. John’s Wort with sertraline because it can increase the risk of a rare but serious condition called serotonin syndrome. Serotonin syndrome can cause symptoms such as confusion, hallucination, seizure, extreme changes in blood pressure, increased heart rate, fever, excessive sweating, shivering or shaking, blurred vision, muscle spasm or stiffness, tremor, incoordination, stomach cramp, nausea, vomiting, and diarrhea.
B. Black cohosh.
Choice B. Black cohosh is wrong because it is a herbal supplement that is used to treat menopausal symptoms and has no known interaction with sertraline.
C. Coenzyme Q.
Choice C. Coenzyme Q is wrong because it is a natural substance that is involved in energy production and has no known interaction with sertraline.
D. Ginger root.
Choice D. Ginger root is wrong because it is a spice that is used to treat nausea and has no known interaction with sertraline.
Full Explanation
The nurse should advise the client to avoid taking St. John’s Wort with sertraline because it can increase the risk of a rare but serious condition called serotonin syndrome. Serotonin syndrome can cause symptoms such as confusion, hallucination, seizure, extreme changes in blood pressure, increased heart rate, fever, excessive sweating, shivering or shaking, blurred vision, muscle spasm or stiffness, tremor, incoordination, stomach cramp, nausea, vomiting, and diarrhoea.
Choice B. Black cohosh is wrong because it is a herbal supplement that is used to treat menopausal symptoms and has no known interaction with sertraline.
Choice C. Coenzyme Q is wrong because it is a natural substance that is involved in energy production and has no known interaction with sertraline.
Choice D. Ginger root is wrong because it is a spice that is used to treat nausea and has no known interaction with sertraline.