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When administering an intravenous infusion of monoclonal antibodies, it is most important for the nurse to implement which of the following interventions?

Restrict the client’s intake of fluids.

Premedicate the client with morphine.

Stay with the client during the first 15 minutes of the infusion.

Assess the client for the development of ototoxicity.

Answer and Explanation

The Correct Answer is C

A. Restrict the client’s intake of fluids.

Fluid restriction is not a standard intervention during the administration of monoclonal antibodies.

B. Premedicate the client with morphine.

Morphine is not a standard premedication for monoclonal antibody infusions. Premedication may be used in some cases, but the specific medications used depend on the patient's individual needs and the nature of the monoclonal antibody being administered.

C. Stay with the client during the first 15 minutes of the infusion.

The rationale for staying with the client during the initial part of the infusion is to monitor for any immediate hypersensitivity reactions or infusion-related adverse events, which can sometimes occur early in the infusion process. This allows the nurse to respond promptly if the client experiences any adverse reactions.

D. Assess the client for the development of ototoxicity.

Ototoxicity (hearing loss) is not a common concern with monoclonal antibody infusions. The focus of assessment during the infusion is primarily on immediate hypersensitivity reactions and other infusion-related adverse events.

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Correct Answer is C

Explanation

Explanation:

A. Administer phenergan (Promethazine) 12.5 mg IVP at the first complaint of nausea.

This option suggests waiting until the patient complains of nausea before administering the antiemetic. It is not a proactive approach and may not effectively prevent nausea associated with chemotherapy.

B. Administer ondansetron (Zofran) 4mg IV Push after Ms. Samuels complains of nausea.

Similar to option A, this choice involves waiting for the patient to experience nausea before administering the medication. Again, it is not a proactive strategy for preventing chemotherapy-induced nausea and vomiting.

C. Administer ondansetron (Zofran) 4mg IV push sometime between 1300-1330.

This option is the most appropriate among the given choices. It suggests administering the antiemetic (ondansetron) before the scheduled chemotherapy session. Ondansetron is commonly used as a prophylactic measure to prevent nausea and vomiting associated with chemotherapy.

D. Administer phenergan (Promethazine) 25 mg PO at 1345.

This choice involves administering the antiemetic (phenergan) orally just 15 minutes before the scheduled chemotherapy session. While it is better than waiting for symptoms to appear, oral medications may take some time to be absorbed, and it might not provide as rapid relief as an intravenous (IV) medication.

A. Avoid elevated altitudes of greater than 2,000 feet (if possible) and air travel for 2-4 weeks (depending on the oncologist’s advice). B. Avoid foods high in purine for 30-90 days (depending on the oncologist’s advice). C. Avoid sun exposure for 60-90 days following chemotherapy (depending on oncologist’s advice). D. Have a solid plan for contraception for 3 months to 2 years (depending on the oncologist’s advice).

Correct Answer is C

Explanation

A. Avoid elevated altitudes of greater than 2,000 feet (if possible) and air travel for 2-4 weeks (depending on the oncologist’s advice):

Altitude and air travel restrictions are not common recommendations after completing chemotherapy.

B. Avoid foods high in purine for 30-90 days (depending on the oncologist’s advice):

Restrictions on foods high in purine are not typically associated with post-chemotherapy care.

C. Avoid sun exposure for 60-90 days following chemotherapy (depending on oncologist’s advice):

Chemotherapy can make the skin more sensitive to sunlight. Advising the patient to avoid sun exposure or take precautions such as using sunscreen can help prevent skin damage during this period.

D. Have a solid plan for contraception for 3 months to 2 years (depending on the oncologist’s advice):

Contraception considerations may be important, but the timeframe mentioned is not a standard recommendation following chemotherapy completion. The need for contraception may vary depending on the patient's overall health, reproductive goals, and specific chemotherapy drugs received. This decision is usually discussed with the healthcare provider on an individual basis.

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When administering an intravenous infusion of monoclonal antibodies, it is most important for the nurse to implement which of the following interventions?

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Correct Answer is C

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