Nokea
Select the complication of intravenous therapy that is accurately paired with one of its interventions.
- A. Infection: Lowering the limb to promote circulation
- B. Infiltration: The application of cold to the site
- C. Extravasation: The aspiration of contents including blood from the IV cannula
- D. Hematoma: The administration of dexrazoxane
Correct Answer: C
Rationale: Aspirating contents from the IV cannula is an intervention for extravasation to remove vesicant drugs and minimize tissue damage.
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The nurse evaluates a client's knowledge as deficient when the client makes which of the following statements about the drug dexamethasone (Decadron)?
- A. I cannot stop the Decadron all at one time.'
- B. If I forget a dose, it's no big deal; I'll just take it when I remember it.'
- C. When I get a cold, I need to let my doctor know.'
- D. I need to watch for an allergic reaction when I first start taking Decadron.'
Correct Answer: B
Rationale: Dexamethasone requires consistent dosing, and missing a dose can have significant effects, indicating a need for further instruction.
The mother of the child diagnosed with Kawasaki disease asks the nurse about the disorder. On which description of this disorder should the nurse base the response to the mother?
- A. It is an acquired cell-mediated immunodeficiency disorder.
- B. It is a chronic multisystem autoimmune disease characterized by the inflammation of connective tissue.
- C. It is also called mucocutaneous lymph node syndrome and is a febrile generalized vasculitis of unknown etiology.
- D. It is an inflammatory autoimmune disease that affects the connective tissue of the heart, joints, and subcutaneous tissues.
Correct Answer: C
Rationale: Kawasaki disease, also called mucocutaneous lymph node syndrome, is a febrile generalized vasculitis of unknown etiology. Option 1 describes human immunodeficiency virus infection. Option 2 describes systemic lupus erythematosus. Option 4 describes rheumatic fever.
The nurse is obtaining a health history from a Mexican American adult. The nurse should interpret the findings by understanding that Mexican American culture most highly values:
- A. Children
- B. Materialism
- C. Firstborn sons
- D. The elderly
Correct Answer: A
Rationale: Mexican American culture often places high value on children, emphasizing family and intergenerational bonds. Materialism, firstborn sons, and the elderly are valued but not as universally central.
The nurse is caring for a client with a history of burns covering 30% of the body. Which of the following interventions should be prioritized?
- A. Administer I.V. fluids.
- B. Apply antibiotic cream.
- C. Monitor for infection.
- D. Administer analgesics.
Correct Answer: A
Rationale: I.V. fluids are the priority to replace fluid loss and prevent hypovolemic shock in burn injuries.
A client has been taking benzonatate as prescribed. The nurse should tell the client this medication performs which action?
- A. Increases comfort level
- B. Decreases anxiety level
- C. Calms the persistent cough
- D. Takes away nausea and vomiting
Correct Answer: C
Rationale: Benzonatate is a locally acting antitussive. Its effectiveness is measured by the degree to which it decreases the intensity and frequency of cough, without eliminating the cough reflex. The remaining options are not intended effects of this medication.