A nurse is preparing to administer epoetin to a client who has anemia due to chemotherapy. Which of the following actions should the nurse plan to take?

Review the client’s Hgb level prior to administration.

Use the Z-track method when administering the medication.

Shake the vial for 30 seconds prior to withdrawing the medication.

Ensure the client is not taking iron supplements while on this medication.

Answer and Explanation

The Correct Answer is A

Choice A Reason

Review the client’s Hgb level prior to administration. This is the correct action. Monitoring hemoglobin (Hgb) levels is crucial before administering epoetin because it helps determine the appropriate dosage and ensures the treatment is safe and effective. Epoetin is used to stimulate red blood cell production, and administering it without checking Hgb levels can lead to complications such as hypertension or thromboembolic events if the Hgb level is too high.

Choice B Reason

Use the Z-track method when administering the medication. This statement is incorrect. The Z-track method is used for intramuscular injections to prevent medication from leaking into subcutaneous tissues. Epoetin is typically administered subcutaneously or intravenously, not intramuscularly, so the Z-track method is not applicable.

Choice C Reason

Shake the vial for 30 seconds prior to withdrawing the medication. This statement is incorrect. Shaking the vial of epoetin can damage the protein structure of the medication, rendering it ineffective. The vial should be gently swirled if necessary, but not shaken.

Choice D Reason

Ensure the client is not taking iron supplements while on this medication. This statement is incorrect. Iron supplements are often necessary when administering epoetin because iron is required for the production of hemoglobin. Ensuring adequate iron levels helps maximize the effectiveness of epoetin therapy.

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Correct Answer is A

Explanation

Choice A Reason:

A red tag is used to label those who cannot survive without immediate treatment but who have a chance of survival. The child’s respiratory rate of 8/min, unresponsiveness to verbal commands, and groaning to painful stimuli indicate severe injuries that require urgent medical attention. Immediate intervention is necessary to address potential life-threatening conditions.

Choice B Reason:

A yellow tag is assigned to those who require observation and possible later re-triage. Their condition is stable for the moment, and they are not in immediate danger of death. Given the child’s critical condition, a yellow tag would not be appropriate as it suggests the child can wait for treatment, which is not the case here.

Choice C Reason:

A green tag is for the “walking wounded” who will need medical care at some point after more critical injuries have been treated. This tag is not suitable for the child in question, as their condition is far from minor and requires immediate attention.

Choice D Reason:

A black tag is used for the deceased or those whose injuries are so severe that they are not expected to survive despite receiving care. While the child’s condition is critical, they still have a chance of survival with immediate treatment, making a black tag inappropriate.

A. Your provider will use your digital rectal examination to perform the test. B. Your provider will prescribe a stimulant laxative prior to the procedure to evacuate the bowel. C. You should begin annual fecal occult blood testing for colorectal cancer screening at 40 years old. D. You should avoid taking corticosteroids prior to testing.

Correct Answer is D

Explanation

Choice A Reason:

The statement that “Your provider will use your digital rectal examination to perform the test” is incorrect. A fecal occult blood test (FOBT) typically involves collecting stool samples at home over several days, not during a digital rectal examination. The samples are then sent to a lab for analysis to detect hidden blood in the stool.

Choice B Reason:

The statement that “Your provider will prescribe a stimulant laxative prior to the procedure to evacuate the bowel” is also incorrect. There is no need for a stimulant laxative before an FOBT. The test requires normal bowel movements to detect any hidden blood in the stool.

Choice C Reason:

The recommendation to “begin annual fecal occult blood testing for colorectal cancer screening at 40 years old” is not accurate. Current guidelines generally recommend starting colorectal cancer screening at age 45 for individuals at average risk. However, those with higher risk factors may need to start earlier, based on their healthcare provider’s advice.

Choice D Reason:

The statement “You should avoid taking corticosteroids prior to testing” is correct. Certain medications, including corticosteroids, can cause gastrointestinal bleeding, which may lead to false-positive results in an FOBT. Therefore, it is important to avoid these medications before the test, as advised by a healthcare provider.

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A nurse is preparing to administer epoetin to a client who has anemia due to chemotherapy. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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