Which of the following statements regarding colloid administration does the nurse identify as being true?

Correct Answer: D

Rationale: The statement "Dextran therapy can cause anaphylaxis or renal failure" is true. Dextran is a type of colloid solution that can cause allergic reactions such as anaphylaxis in some individuals. It can also lead to kidney damage, which is why monitoring for signs of renal failure is crucial when administering Dextran. As a result of these potential risks, dextran therapy should be used cautiously and patients should be closely monitored for adverse reactions.

Correct Answer: D

Rationale: Erectile dysfunction drugs, such as Viagra (sildenafil), Cialis (tadalafil), and Levitra (vardenafil), are contraindicated with nitroglycerin. Both nitroglycerin and erectile dysfunction drugs can cause a sudden decrease in blood pressure when taken together, leading to a serious drop in blood pressure. This could result in dizziness, lightheadedness, fainting, and even potentially life-threatening complications like a heart attack or stroke. Therefore, it is crucial to avoid the combination of nitroglycerin with erectile dysfunction medications to prevent these adverse effects.

Correct Answer: D

Rationale: Tinnitus, or ringing in the ears, can be an early sign of aspirin toxicity. Aspirin poisoning can lead to salicylate toxicity, which can manifest with various symptoms including tinnitus, along with hyperventilation, nausea, vomiting, and metabolic acidosis. Monitoring for tinnitus is crucial as an early indicator of potential aspirin overdose in clients. Unsteady gait, drowsiness, and confusion are also symptoms of aspirin toxicity but typically develop after tinnitus in the progression of toxicity.

Correct Answer: B

Rationale: Before administering Digoxin, it is crucial for the nurse to count the patient's apical pulse for 1 minute. Digoxin is a medication commonly prescribed to manage heart conditions such as heart failure and certain irregular heartbeats. Since Digoxin works by helping the heart beat stronger and at a more normal rhythm, it is essential to monitor the patient's heart rate before administering the medication. Counting the apical pulse for 1 minute allows for an accurate assessment of the patient's baseline heart rate, which is crucial in determining whether it is safe to administer Digoxin. If the heart rate is too low (bradycardia), administering Digoxin could potentially cause further complications. Therefore, assessing the apical pulse beforehand is a critical step in ensuring the safe administration of Digoxin.

Correct Answer: A

Rationale: Warfarin is an anticoagulant medication commonly used to prevent blood clots. One of the most severe adverse effects of warfarin is the risk of bleeding. This can occur in various parts of the body, such as the gastrointestinal tract, brain, or other organs. Bleeding complications can range from minor bruising to life-threatening hemorrhages, especially if warfarin levels are not properly monitored. Patients taking warfarin should be closely monitored for signs of bleeding, and their medication dosages should be adjusted as needed to maintain a balance between preventing clotting and avoiding excessive bleeding.