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?
Discard the medication if it is yellow.
Use a gravity flow set.
Prime the tubing with 0.9% sodium chloride.
Administer the medication over 2 hr.
The Correct Answer is D
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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The most appropriate action for the nurse to take in this situation is:
d. Apply a warm, moist compress.
Here's why the other options are not recommended:
- a. Initiate a new IV distal to the initial site:This is not the first course of action. While starting a new IV might be necessary eventually, it's crucial to address the issue at the current site first.
- b. Slow the IV solution rate:Slowing the rate doesn't directly address the coolness and edema, which indicate potential infiltration or extravasation.
- c. Maintain the extremity below the level of the heart:This action would actually worsen the edema by promoting fluid accumulation at the site.
Applying a warm, moist compress can help promote absorption of any leaked fluid and improve circulation at the site. However, it's important to remember that this is just one step in the process. The nurse should also:
- Stop the IV infusion.
- Assess the extent of the infiltration or extravasation.
- Document the findings.
- Elevate the affected extremity.
- Consult with a physician for further instructions and potential treatment.
Correct Answer is D
Explanation
This is because swelling of the feet can be a sign of lithium toxicity, which is a serious condition that can occur when the level of lithium in the blood is too high. Lithium toxicity can cause confusion, irregular heartbeat, muscle weakness, and kidney problems. Therefore, the client should report any signs of lithium toxicity to their provider as soon as possible.
Choice A is wrong because limiting foods containing tyramine is not necessary for clients taking lithium. Tyramine is a substance found in some foods that can interact with certain antidepressants called monoamine oxidase inhibitors (MAOIs), but not with lithium.
Choice B is wrong because decreasing the daily sodium intake can actually increase the risk of lithium toxicity.
Sodium helps to regulate the amount of lithium in the body, so if the sodium level is low, the lithium level can rise too high.
The client should maintain a normal sodium intake and drink enough fluids while taking lithium.
Choice C is wrong because taking this medication 2 hours before a meal is not required for clients taking lithium.
Lithium can be taken with or without food, but it should be taken at the same time each day to keep a steady level in the blood.
Taking lithium 2 hours before a meal may cause stomach upset, which is a common side effect of lithium.
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