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.
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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Related Questions
Correct Answer is D
Explanation
A. The inhaled form may cause more side effects than the oral form.
The route of administration does not necessarily determine the likelihood of side effects. Both inhaled and oral forms of albuterol can cause side effects, but they may vary in nature.
B. The inhaled form requires an increased dose.
The dose of albuterol may differ between inhaled and oral forms, but it is not accurate to say that the inhaled form always requires an increased dose. The choice of dosage depends on factors such as the severity of symptoms and the patient's response to treatment.
C. The inhaled form will not lead to increased doses.
The need for increased doses depends on the individual patient's response and the severity of symptoms. In some cases, increased doses may be necessary, especially during acute exacerbations.
D. The inhaled form has a more immediate onset of action.
Inhaled albuterol has a quicker onset of action compared to the oral form. When inhaled, the medication reaches the airways directly, leading to rapid bronchodilation and relief of symptoms. This is especially important during acute bronchoconstriction or asthma exacerbations when prompt relief is needed.
Correct Answer is ["C"]
Explanation
A. Remove the intravenous catheter.
While removing the intravenous catheter is an important step, the immediate priority in cases of extravasation is to stop the infusion to prevent further leakage into the surrounding tissues. After stopping the infusion, the catheter can be carefully removed.
B. Pack the intravenous site with ice.
Cold compresses or ice packs are sometimes used in the management of certain types of extravasation to help reduce local swelling and vasoconstriction. However, the immediate priority is to stop the infusion (Choice C). After that, specific interventions, such as warm or cold compresses, may be employed based on the specific chemotherapy agent involved.
C. Stop the intravenous infusion.
This is the correct answer. Stopping the infusion is the first and most immediate action to prevent further leakage of the chemotherapy drug into the surrounding tissues, reducing the risk of tissue damage and adverse effects.
D. Attempt to aspirate residual medication from the patient’s vein.
While aspirating residual medication may be part of the overall management of extravasation, it is not the first action. The priority is to stop the infusion to prevent further damage. After stopping the infusion, the nurse may assess the situation and determine whether aspirating residual medication is appropriate.
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