A nurse is planning care for a client who is receiving morphine via continuous epidural infusion. The nurse should monitor the client for which of the following adverse effects?

Pruritus

Gastric bleeding

Tachypnea

Cough

Answer and Explanation

The Correct Answer is A

A. Pruritus, which is itching, is a common adverse effect associated with the use of opioids, including morphine. Itching can occur when opioids are administered through various routes, including epidural infusion. The exact mechanism for opioid-induced itching is not fully understood, but it is thought to be related to the release of histamines or other chemical mediators.
B. Gastric bleeding is not a common adverse effect of epidurally administered opioids like morphine. Gastric bleeding is more associated with non-steroidal anti-inflammatory drugs (NSAIDs) and certain other medications.
C & D. Tachypnea (rapid breathing) and cough are not typical adverse effects of epidurally administered opioids. However, opioids can cause respiratory depression (slow and shallow breathing), so monitoring respiratory status is important when using these medications.

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Correct Answer is B

Explanation

A. Pedal edema
Explanation: Pedal edema (swelling of the feet) is not a typical sign of an acute infusion reaction to IV amphotericin B.
B. Fever
Explanation: Fever is a common sign of an acute infusion reaction, indicating an inflammatory response to the medication.
An acute infusion reaction to IV amphotericin B is most commonly characterized by fever and chills, as well as other flu-like symptoms such as headache, muscle or joint pain, and sometimes a dry cough. Fever is a key indicator of an acute reaction to amphotericin B, and the presence of fever during or after administration should raise concern and prompt the nurse to take appropriate action, including notifying the healthcare provider and discontinuing the infusion.
Pedal edema and hyperglycemia are not typically associated with acute infusion reactions to amphotericin B and are not common manifestations of this type of reaction.
C. Hyperglycemia
Explanation: Hyperglycemia (high blood sugar) is not typically associated with an acute infusion reaction to IV amphotericin B.
D. Dry cough
Explanation: A dry cough can be a symptom of an acute infusion reaction, potentially indicating irritation or inflammation of the respiratory tract.

A. Replace the infusion with 0.9% sodium chloride. B. Give diphenhydramine IM. C. Elevate the client's legs and feet. D. Administer epinephrine IM.

Correct Answer is D

Explanation

A. Replace the infusion with 0.9% sodium chloride:
Incorrect Explanation: While replacing the infusion with a different solution might be considered later, it's not the immediate next step.
Explanation: The primary concern during an anaphylactic reaction is ensuring the client's airway, breathing, and circulation. Addressing the medication infusion should come after stabilizing the client's condition.
B. Give diphenhydramine IM:
Incorrect Explanation: Administering diphenhydramine (an antihistamine) can be beneficial, but it's not the initial priority.
Explanation: Diphenhydramine can help mitigate allergic symptoms, but it's not the first-line treatment for severe anaphylaxis.
C. Elevate the client's legs and feet:
Incorrect Explanation: Elevating the legs and feet is not the appropriate action for managing anaphylaxis.
Explanation: During anaphylaxis, maintaining the airway, ensuring proper circulation, and administering appropriate medications take precedence over elevating the legs.
D. Administer epinephrine IM:
Correct Answer: Administering epinephrine (adrenaline) IM is the appropriate next step in managing anaphylaxis.
Explanation: Epinephrine is the first-line treatment for severe anaphylactic reactions. It helps counteract the symptoms of anaphylaxis by constricting blood vessels, improving circulation, and opening airways. Epinephrine should be administered promptly and followed by seeking emergency medical care.

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A nurse is planning care for a client who is receiving morphine via continuous epidural infusion. The nurse should monitor the client for which of the following adverse effects?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

A nurse is caring for a client who develops an anaphylactic reaction to IV antibiotic administration. After assessing the client's respiratory status and stopping the medication infusion, which of the following actions should the nurse take next?

Correct Answer is D

Explanation

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