Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is preparing to administer amphotericin B lipid complex via intermittent IV bolus to a client who has infective endocarditis. Which of the following actions should the nurse take?
A. Discard the medication if it is yellow.
Discarding the medication if it is yellow is not necessary. The color of amphotericin B lipid complex does not indicate its effectiveness or safety.
B. Use a gravity flow set.
Using a gravity flow set is not specifically required for the administration of amphotericin B lipid complex. Gravity infusion can be used to administer fluids and drugs where the rate is not critical and serious adverse effects are not anticipated. However, the use of a gravity flow set is not specifically mentioned in the guidelines for administering amphotericin B lipid complex.
C. Prime the tubing with 0.9% sodium chloride.
Priming the tubing with 0.9% sodium chloride is not recommended for amphotericin B lipid complex. This is because amphotericin B lipid complex is incompatible with saline solutions and should be diluted only with 5% dextrose injection. Priming the tubing is a common practice in IV therapy to remove air from the tubing before attaching it to the patient.
D. Administer the medication over 2 hr.
Administering the medication over 2 hr is the correct action. Amphotericin B lipid complex is typically administered over a longer period, often 2-6 hours. This allows for a slow and steady delivery of the medication, which can help to minimize potential side effects.
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
The correct answer is d. Administer the medication over 2 hr.
Choice A reason: Discarding the medication if it is yellow is not necessary. The color of amphotericin B lipid complex does not indicate its effectiveness or safety.
Choice B reason: Using a gravity flow set is not specifically required for the administration of amphotericin B lipid complex. Gravity infusion can be used to administer fluids and drugs where the rate is not critical and serious adverse effects are not anticipated. However, the use of a gravity flow set is not specifically mentioned in the guidelines for administering amphotericin B lipid complex.
Choice C reason: Priming the tubing with 0.9% sodium chloride is not recommended for amphotericin B lipid complex. This is because amphotericin B lipid complex is incompatible with saline solutions and should be diluted only with 5% dextrose injection. Priming the tubing is a common practice in IV therapy to remove air from the tubing before attaching it to the patient.
Choice D reason: Administering the medication over 2 hr is the correct action. Amphotericin B lipid complex is typically administered over a longer period, often 2-6 hours. This allows for a slow and steady delivery of the medication, which can help to minimize potential side effects.
Similar Questions
A nurse is assessing a client who is taking an osmotic laxative.
Which of the following findings should the nurse identify as an indication of fluid volume deficit?
A. Oliguria.
Osmotic laxatives work by drawing water into the colon to soften the stool and stimulate bowel movements. However, excessive use of osmotic laxatives can cause fluid volume deficit, which is a state of reduced intravascular volume.
B. Nausea.
Nausea is wrong because nausea is a common side effect of osmotic laxatives, not an indication of fluid volume deficit.
C. Headaches.
Headaches are wrong because headaches are more likely to be caused by dehydration, which is a state of reduced total body water, mostly affecting the intracellular fluid compartment. Dehydration can result from osmotic laxatives, but it is not the same as fluid volume deficit.
D. Weight gain.
Weight gain is wrong because weight gain is not a sign of fluid volume deficit.
Full Explanation
Osmotic laxatives work by drawing water into the colon to soften the stool and stimulate bowel movements. However, excessive use of osmotic laxatives can cause fluid volume deficit, which is a state of reduced intravascular volume.
One of the signs of fluid volume deficit is oliguria, which means low urine output.
Choice B. Nausea is wrong because nausea is a common side effect of osmotic laxatives, not an indication of fluid volume deficit.
Choice C. Headaches is wrong because headaches are more likely to be caused by dehydration, which is a state of reduced total body water, mostly affecting the intracellular fluid compartment.
Dehydration can result from osmotic laxatives, but it is not the same as fluid volume deficit.
Choice D. Weight gain is wrong because weight gain is not a sign of fluid volume deficit.
A nurse is assessing a client who is receiving heparin via continuous IV. The client has an aPTT of 90 seconds. The nurse should monitor the client for which of the following changes in their vital signs?
A. Increased pulse rate.
An aPTT of 90 seconds is much higher than the normal range of 30-40 seconds, which means the blood takes longer to clot and the client is at risk of bleeding. An increased pulse rate is a sign of blood loss and shock.
B. Increased blood pressure.
Hypotension, not hypertension, is a sign of significant blood loss.
C. Decreased temperature.
While severe shock can lead to hypothermia, temperature changes are not an early indicator of heparin overdose.
D. Decreased respiratory rate.
If bleeding leads to hypovolemic shock, respiratory rate would likely increase, not decrease.
Full Explanation
An aPTT of 90 seconds is much higher than the normal range of 30-40 seconds, which means the blood takes longer to clot and the client is at risk of bleeding. An increased pulse rate is a sign of blood loss and shock.
Choice B is wrong because increased blood pressure is not a sign of bleeding, but rather a sign of hypertension or stress.
Choice C is wrong because decreased temperature is not a sign of bleeding, but rather a sign of hypothermia or infection.
Choice D is wrong because decreased respiratory rate is not a sign of bleeding, but rather a sign of respiratory depression or sedation.
A nurse is assessing a client who is receiving intravenous therapy. The nurse should identify which of the following findings as a manifestation of fluid volume excess?
A. Decreased bowel sounds.
Choice A is wrong because decreased bowel sounds are not related to fluid volume excess. Decreased bowel sounds can indicate ileus, obstruction, or peritonitis.
B. Bilateral muscle weakness.
Choice B is wrong because bilateral muscle weakness is not a sign of fluid volume excess. Bilateral muscle weakness can be caused by electrolyte imbalances, neuromuscular disorders, or stroke.
C. Thready pulse.
Choice C is wrong because thready pulse is a sign of fluid volume deficit, not excess. Thready pulse indicates poor perfusion and low cardiac output, which can result from dehydration, hemorrhage, or shock.
D. Distended neck veins
Distended neck veins are a sign of increased central venous pressure, which can result from fluid volume excess. Fluid volume excess can also cause edema, crackles in the lungs, and increased blood pressure.
Full Explanation
Distended neck veins are a sign of increased central venous pressure, which can result from fluid volume excess. Fluid volume excess can also cause edema, crackles in the lungs, and increased blood pressure.
Choice A is wrong because decreased bowel sounds are not related to fluid volume excess.
Decreased bowel sounds can indicate ileus, obstruction, or peritonitis. Choice B is wrong because bilateral muscle weakness is not a sign of fluid volume excess.
Bilateral muscle weakness can be caused by electrolyte imbalances, neuromuscular disorders, or stroke.
Choice C is wrong because thready pulse is a sign of fluid volume deficit, not excess.
Thready pulse indicates poor perfusion and low cardiac output, which can result from dehydration, hemorrhage, or shock.