Nokea
Mr. L (tracheostomy and partial laryngectomy) needs to receive a dose of IV chemotherapy during the shift. What is the most important action to take to prevent extravasation?
- A. Carefully monitor the access site during the administration of the medication.
- B. Hold the medication until an implanted port or central line is established.
- C. Ensure that a chemotherapy-certified nurse is assigned to care for the client.
- D. Call the pharmacy to find out if the prescribed medication has vesicant properties.
Correct Answer: A
Rationale: Step-by-step rationale for the correct answer, A:
1. Monitoring the access site during administration allows for early detection of extravasation.
2. Early detection can prevent serious tissue damage and complications.
3. As Mr. L has a tracheostomy and partial laryngectomy, his airway is compromised, making prevention of extravasation crucial.
4. This action is within the nurse's scope of practice and promotes patient safety.
Summary:
- Choice B is incorrect as delaying treatment can impact Mr. L's health.
- Choice C is not directly related to preventing extravasation.
- Choice D, though important, does not directly address preventing extravasation during administration.
You may also like to solve these questions
One study of Italian primary care physicians caring for diabetic patients showed that those scoring highest on the empathy test had patients with:
- A. Significantly fewer acute diabetic complications
- B. Statistically fewer acute diabetic complications
- C. Higher rates of chronic diabetic complications
- D. Statistically higher poor outcomes for patients with diabetes
Correct Answer: B
Rationale: The correct answer is B: Statistically fewer acute diabetic complications. This is because the study found a correlation between high empathy scores of physicians and lower occurrences of acute diabetic complications in their patients. The use of the term "statistically" implies a significant and reliable relationship between physician empathy and patient outcomes.
Choice A is incorrect because the study did not specify "significantly" fewer complications, only a correlation with high empathy scores. Choice C is incorrect as there was no evidence of higher rates of chronic complications associated with physician empathy. Choice D is incorrect as the study did not find statistically higher poor outcomes for patients with diabetes, but rather a relationship with fewer acute complications.
The nurse cares for a female patient who is trying to gain understanding of her life and her diagnosis of metastatic breast cancer. Which approach by the nurse would best meet this patient's needs?
- A. Suggest the patient join a breast cancer support group.
- B. Provide the patient with reading material on death and dying.
- C. Contact the patient's spiritual leader to request daily visits.
- D. Listen to the patient's stories about her past experiences.
Correct Answer: D
Rationale: The correct answer is D because actively listening to the patient's stories about her past experiences allows for emotional expression, validation, and building trust. It promotes therapeutic communication and helps the patient gain understanding and cope with her diagnosis. Choice A focuses on group support, which may not address the patient's individual needs. Choice B is not appropriate as it may induce unnecessary fear. Choice C assumes the patient has specific spiritual beliefs and may not be welcomed.
A patient who has had a stroke is unable to speak clearly and has right sided hemiplegia. The nurse will design the approach to the assessment interview by:
- A. asking questions and explaining procedures to the patient's daughter.
- B. speaking slowly and giving the patient time to respond.
- C. telling the patient he will get all necessary information from the daughter.
- D. prompting the answers and finishing the sentences for the patient. Speaking slowly recognizes that the patient may process (if able) information more slowly.
Correct Answer: B
Rationale: The correct answer is B because speaking slowly and giving the patient time to respond allows the patient with speech difficulties due to the stroke to process information and formulate a response. Prompting or finishing sentences can hinder the patient's ability to communicate independently. Asking questions to the patient directly, rather than relying on a family member, ensures accurate information is obtained directly from the patient. Telling the patient that all information will come from the daughter undermines the patient's autonomy and may lead to incomplete or inaccurate information.
The nurse sees that Mr. B (bladder cancer) has received docusate for the past 2 days. Which question is the nurse most likely to ask to evaluate the effectiveness of the docusate?
- A. "Are you experiencing any burning with urination?"
- B. "Did you have a bowel movement today or yesterday?"
- C. "Has the medication helped to relieve the nausea?"
- D. "Were you able to sleep soundly the last couple of nights?"
Correct Answer: B
Rationale: The correct answer is B. Docusate is a stool softener commonly used to prevent constipation, which is a common side effect of opioid pain medications. By asking if the patient had a bowel movement today or yesterday, the nurse can evaluate the effectiveness of docusate in facilitating bowel movements. This question directly assesses the expected outcome of the medication.
A: "Are you experiencing any burning with urination?" - This question is more relevant to urinary tract infections, not related to docusate use for constipation.
C: "Has the medication helped to relieve the nausea?" - Docusate is not typically used to relieve nausea, so this question is not relevant to evaluating its effectiveness.
D: "Were you able to sleep soundly the last couple of nights?" - This question is not directly related to the expected outcome of docusate in treating constipation.
When a patient states, "My son hasn't been to see me in months," the nurse's best verbal response is:
- A. "Don't worry; I'm sure your son will visit."
- B. "Your son hasn't been around much lately?"
- C. "My son doesn't come to visit me either."
- D. "How terrible that he doesn't visit you." Restating in different words what the patient said encourages further communication on that topic.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Reflective listening: Restating the patient's statement shows empathy and understanding.
2. Open-ended question: Encourages patient to share more without assumptions.
3. Non-judgmental: Neutral tone promotes trust and openness.
4. Validates patient's feelings: Acknowledges patient's concerns without dismissing them.
Summary:
A: Provides false reassurance, does not address the patient's feelings.
C: Shifts focus to the nurse, not patient-centered.
D: Implies judgment, may shut down communication.