The nurse is reviewing lab work prior to administering a client's regularly scheduled subcutaneous injection of epoetin alfa
The nurse notes that the client's hematocrit has dropped from the last time lab was drawn. Which action by the nurse is the most appropriate?
Standard Text: Select all that apply.
1. Discuss this finding with the client's health care provider immediately.
2. Schedule another hematocrit test tomorrow.
3. Give the epoetin alfa and hold pressure on the injection site for 5 minutes.
4. Ask the client, "How have you been feeling?"
5. Ask the lab to verify the lab results.
Correct Answer: 1,4,5
Rationale 1: Some clients with chronic renal failure develop neutralizing antibodies to subcutaneous epoetin alfa, which can lead to a rapidly developing severe anemia known as pure red cell aplasia.
Rationale 2: If the client is developing pure red cell aplasia, waiting until tomorrow could be a critical error.
Rationale 3: The epoetin alfa should be held.
Rationale 4: Asking how the client has been feeling is the first step in assessing whether anemia is developing.
Rationale 5: A decrease in hematocrit is not the expected effect of administering epoetin alfa and may signal a severe adverse effect. The lab result should be verified.
Global Rationale: Some clients with chronic renal failure develop neutralizing antibodies to subcutaneous epoetin alfa, which can lead to a rapidly developing severe anemia known as pure red cell aplasia. Asking how the client has been feeling is the first step in assessing whether anemia is developing. A decrease in hematocrit is not the expected effect of administering epoetin alfa and may signal a severe adverse effect. The lab result should be verified. If the client is developing pure red cell aplasia, waiting until tomorrow could be a critical error. The epoetin alfa should be held.
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