Nokea
A client with cancer is receiving chemotherapy with a known vesicant. The client's IV has been in place for 72 hours. The nurse determines that a new IV site cannot be obtained, and leaves the present IV in place. What is the greatest clinical risk related to this situation?
- A. Impaired skin integrity
- B. Fluid volume excess
- C. Acute pain and anxiety
- D. Peripheral neurovascular dysfunction
Correct Answer: A
Rationale: Vesicants can cause severe tissue damage if they extravasate, leading to impaired skin integrity.
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Which of the following features favor a diagnosis of restrictive cardiomyopathy over constrictive pericarditis?
- A. Elevated pulmonary artery pressures
- B. Normal BNP levels
- C. Annulus reversus
- D. Ventricular interdependence
Correct Answer: A
Rationale: Restrictive cardiomyopathy is associated with elevated pulmonary artery pressures
Patients at risk for bacterial endocarditis include those with all of the following EXCEPT
- A. repaired simple atrial septic defect
- B. aortic stenosis
- C. rheumatic fever heart disease
- D. palliative vascular shunts
Correct Answer: A
Rationale: Repaired simple atrial septal defects are not considered a risk for bacterial endocarditis unless there are residual defects.
The following factors trigger renin secretion:
- A. Hyponatremia
- B. ACTH
- C. Hypovolemia
- D. ADH
Correct Answer: C
Rationale: Hypovolemia: Renin is secreted by the kidneys in response to low blood volume (hypovolemia), initiating the renin-angiotensin-aldosterone system to conserve sodium and increase blood pressure.
Typical features of Down's syndrome include:
- A. Brachycephaly
- B. Hypotonia
- C. Male infertility
- D. Increased a-fetoprotein in amniotic fluid
Correct Answer: B
Rationale: Hypotonia is a key feature of Down's syndrome, often leading to delayed development and muscle weakness.
Sequelae of a complete posterior cord section between C3 and T1 include:
- A. Muscle fasciculation
- B. Loss of sensation below the lesion
- C. Loss of deep tendon reflexes
- D. Athetoid movements
Correct Answer: B
Rationale: A complete posterior cord section results in loss of sensation below the lesion due to damage to the sensory pathways. Motor functions may remain intact as the anterior cord is unaffected.