A nurse is caring for a client who is in shock and is receiving an infusion of albumin. Which of the following findings should the nurse expect?
PaCO2 30 mm Hg
Oxygen saturation 96
Decrease in protein
Increase in BP
The Correct Answer is D
Choice A rationale:
PaCO2 levels are not typically affected by albumin infusions.
Choice B rationale:
Oxygen saturation of 96 is a normal finding and is not directly related to an albumin infusion.
Choice C rationale:
Albumin infusion would not typically cause a decrease in protein levels. A decrease in protein is not expected after albumin infusion, as albumin is a protein itself.
Choice D rationale:
Albumin is a plasma expander that increases the blood volume and the blood pressure in a client who is in shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Amphotericin B lipid complex is normally yellow in color, so discarding it would be wasteful and inappropriate. The nurse should only discard the medication if it is cloudy, discolored, or contains particulate matter.
Choice B rationale:
Amphotericin B lipid complex should be administered over 1 hr, not 2 hr, to reduce the risk of infusion-related reactions such as fever, chills, rigors, hypotension, and tachycardia. The nurse should also premedicate the client with antipyretics, antihistamines, and corticosteroids to prevent or minimize these reactions.
Choice C rationale:
Priming the tubing with a compatible solution, such as 0.9% sodium chloride, helps prevent the medication from adhering to the tubing and ensures that the full dose reaches the client.
Choice D rationale:
Amphotericin B lipid complex should be administered using an infusion pump, not a gravity flow set, to ensure accurate and consistent delivery of the medication. The nurse should also use a filter needle when drawing up the medication from the vial and a 5-micron filter when infusing it to remove any impurities or aggregates.
Correct Answer is D
Explanation
Choice A rationale:
An INR of 1.6 is slightly elevated but does not necessarily warrant an incident report.
Choice B rationale:
A WBC count of 6,000/mm3 is within a normal range and would not warrant an incident report.
Choice C rationale:
A hemoglobin level of 16 g/dL is within a normal range and does not warrant an incident report.
Choice D rationale:
An aPTT of 90 seconds is significantly prolonged and may indicate excessive anticoagulation from the heparin administration. This could potentially be a safety concern and would warrant an incident report for further evaluation.
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