The nurse is caring for a child who is experiencing acute renal transplant rejection. Which of the following would the nurse most likely expect to find after the child receives the first dose of Muromonab-CD3?
A) Fever with chills, chest tightness
B) Cough, hyperkalemia
C) Photosensitivity, GI upset
D) Urinary retention, decreased appetite
A
Response:
The first dose of Muromonab-CD3 can cause fever, chills, chest tightness, wheezing, and nausea/vomiting. Cough and hyperkalemia are associated with ACE inhibitors. Photosensitivity and GI upset is often associated with diuretics. Urinary retention and decreased appetite are associated with imipramine.
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An adult patient being assessed in the emergency room is anxious about his health status. The ECG rhythm strip shows a heart rate of 120 beats/min. Characteristics of a sinus tachycardia rhythm are:
A) P:QRS ratio of 2:1 B) P:QRS ratio of 1:1 C) Ventricular and atrial rhythm are irregular D) Atrial rhythm regular, ventricular rhythm irregular
The nurse understands that negative-pressure wound therapy may be used in the treatment of partial-thickness burn wounds to do which of the following?
a. Maintain a closed wound system to decrease the risk of infection. b. Remove excessive wound fluid and promote moist wound healing. c. Increase patient mobility with large burn wounds. d. Quantify wound drainage amount for more accurate output assessment.
A 76-year-old postsurgical diabetic patient has reported feeling dizzy and clammy
The daily serum glucose level shows the patient's levels to be within normal limits. The geriatric nurse shows an understanding of established health norms for the older adult when stating: a. "This patient's normal may not be within the typical lab norms." b. "I'll ask the lab to rerun the test so we can double-check the results." c. "There must be another reason for the symptoms." d. "I'll compare the patient's baseline lab work with today's results."
Which nursing intervention is appropriate in the management of the preterm infant with hypothermia? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply
1. Warm the baby rapidly to reverse the hypothermia. 2. Monitor skin temperature every 2 hours to determine whether the infant's temperature is increasing. 3. Keep IV fluids at room temperature. 4. Initiate efforts to maintain the newborn in a neutral thermal environment. 5. Warm the baby slowly to reverse hypothermia and reach a neutral thermal environment.