CRNI Infusion-Related Pharmacology Questions and Answers 1 — Questions and Answers
Question 1: A patient receiving an initial infusion of a new monoclonal antibody develops urticaria, dyspnea, and hypotension. After stopping the infusion, which pharmacologic agent should the certified registered nurse infusion (CRNI) anticipate administering as the first-line treatment for this reaction?
- Intravenous diphenhydramine
- Subcutaneous or intramuscular epinephrine (Correct answer)
- A rapid bolus of 0.9% Sodium Chloride
- Intravenous methylprednisolone
Correct answer: Subcutaneous or intramuscular epinephrine
The patient is exhibiting signs of anaphylaxis, a life-threatening systemic hypersensitivity reaction. Epinephrine is the primary, first-line medication used to treat anaphylaxis. Its alpha- and beta-adrenergic effects reverse bronchoconstriction, decrease vascular permeability, and support blood pressure. Antihistamines (diphenhydramine) and corticosteroids (methylprednisolone) are important secondary treatments but do not act as rapidly or effectively on the most life-threatening symptoms.
Question 2: A CRNI is preparing to administer an intravenous loading dose of phenytoin. Which of the following practices is essential for safe administration to prevent precipitation?
- Diluting the dose in 5% Dextrose in Water (D5W)
- Administering the drug through a line that has been flushed only with heparin
- Using 0.9% Sodium Chloride as the exclusive solution for dilution and flushing (Correct answer)
- Mixing the phenytoin in the same syringe as a benzodiazepine for sedation
Correct answer: Using 0.9% Sodium Chloride as the exclusive solution for dilution and flushing
Phenytoin has a very high pH and is only compatible with 0.9% Sodium Chloride (Normal Saline). Mixing it with dextrose-containing solutions or other medications will cause a chemical incompatibility, leading to the formation of a crystalline precipitate. The intravenous line must be flushed with normal saline both before and after the phenytoin infusion to clear the line of any incompatible solutions.
Question 3: A patient is prescribed intravenous potassium chloride (KCl) 20 mEq to be added to a 100 mL bag of 0.9% Sodium Chloride. Which action by the nurse is most critical to ensure patient safety during preparation and administration?
- Administering the infusion via gravity drip to avoid pump alarms.
- Ensuring the potassium chloride is thoroughly mixed in the solution bag before infusion. (Correct answer)
- Pushing the KCl directly from a syringe into the patient's IV line for faster effect.
- Using a peripheral catheter smaller than 22-gauge to minimize vein irritation.
Correct answer: Ensuring the potassium chloride is thoroughly mixed in the solution bag before infusion.
It is critical to invert and agitate the IV bag after adding potassium chloride to ensure it is evenly distributed throughout the solution. Failure to mix properly can result in the patient receiving a concentrated bolus of potassium, which can cause life-threatening cardiac arrhythmias and death. Administration via an infusion pump is mandatory for this high-alert medication, IV push is strictly contraindicated, and an appropriate gauge catheter is needed, but ensuring proper mixing is the most critical safety step during preparation.
Question 4: A patient with a peripherally inserted central catheter (PICC) is receiving a continuous infusion of a vesicant chemotherapy agent. The nurse assesses the site and notes swelling, erythema, and a report of pain at the site, but there is still a brisk blood return. What is the most appropriate interpretation of these findings?
- The patient is experiencing an expected local inflammatory reaction to the medication.
- A fibrin sheath has formed at the catheter tip, causing a partial occlusion.
- The patient is developing a central line-associated bloodstream infection (CLABSI).
- An extravasation may be occurring despite the presence of a blood return. (Correct answer)
Correct answer: An extravasation may be occurring despite the presence of a blood return.
Extravasation, the leakage of a vesicant drug into the surrounding tissue, is a serious complication. While a lack of blood return is a key sign of catheter mispositioning, a blood return can still be present in the early stages of an extravasation, especially with central lines. This is sometimes referred to as a 'sentinel event' where the signs of infiltration/extravasation appear before blood return is lost. Given the vesicant nature of the drug and the clinical signs (swelling, pain, erythema), extravasation must be the primary suspicion and requires immediate intervention.
Question 5: A patient receiving intravenous vancomycin begins to experience flushing of the face and neck, pruritus, and a macular rash on the upper torso. The patient's vital signs are stable. The CRNI should recognize these symptoms as being characteristic of which infusion-related reaction?
- Anaphylaxis
- Speed shock
- Vancomycin infusion reaction (Correct answer)
- A pyrogenic reaction
Correct answer: Vancomycin infusion reaction
This constellation of symptoms is characteristic of Vancomycin Infusion Reaction, historically known as 'Red Man Syndrome.' It is a rate-dependent pseudoallergic reaction caused by histamine release, not a true IgE-mediated allergy like anaphylaxis. It is managed by stopping the infusion, treating with antihistamines, and restarting at a slower rate once symptoms resolve. Anaphylaxis would typically involve hypotension and respiratory distress. Speed shock involves systemic symptoms like headache and dizziness from rapid infusion of any drug. A pyrogenic reaction would involve fever and chills.
Question 6: A CRNI is caring for a patient who develops severe respiratory depression after receiving repeated doses of intravenous hydromorphone. The nurse should be prepared to administer which pharmacologic antagonist to reverse the effects of the medication?
- Flumazenil
- Protamine Sulfate
- Acetylcysteine
- Naloxone (Correct answer)
Correct answer: Naloxone
Hydromorphone is a potent opioid analgesic. Naloxone is a pure opioid antagonist that rapidly reverses the effects of opioids, including respiratory depression, sedation, and hypotension. Flumazenil is used to reverse benzodiazepines, protamine sulfate reverses heparin, and acetylcysteine is the antidote for acetaminophen overdose.
CRNI Infusion-Related Pharmacology Questions and Answers 1
A patient receiving an initial infusion of a new monoclonal antibody develops urticaria, dyspnea, and hypotension.
After stopping the infusion, which pharmacologic agent should the certified registered nurse infusion (CRNI) anticipate administering as the first-line treatment for this reaction?