Nokea
The HCP has ordered one (1) unit of packed RBCs for the client who is right-handed. Which area would be the best place to insert the intravenous catheter?
- A. A
- B. B
- C. C
- D. D
Correct Answer: C
Rationale: For a right-handed client, the non-dominant (left) arm is preferred for IV access (C) to maintain function. Specific sites (A, B, D) depend on image, but C is typically left forearm/antecubital.
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Which statement is the scientific rationale for infusing a unit of blood in less than four (4) hours?
- A. The blood will coagulate if left out of the refrigerator for greater than four (4) hours.
- B. The blood has the potential for bacterial growth if allowed to infuse longer.
- C. The blood components begin to break down after four (4) hours.
- D. The blood will not be affected; this is a laboratory procedure.
Correct Answer: B
Rationale: Blood must infuse within 4 hours (B) to minimize bacterial growth risk. Coagulation (A) is not primary, components (C) degrade minimally, and lab procedure (D) is incorrect.
The nurse is administering vesicant chemotherapy medications such as doxorubicin hydrochloride to clients. Which nursing actions should the nurse implement to prevent extravasation?
- A. Give through an IV catheter in a large peripheral vein if infusing in less than 60 minutes.
- B. Check patency every 5 to 10 minutes during infusion and ask about IV site discomfort.
- C. Check the IV pump and alarm for indications of an infiltration of the medication.
- D. Check for blood return in a central venous catheter prior to administration of the vesicant.
- E. Use small-gauged syringes with small barrels when flushing any access devices with saline.
Correct Answer: A, B, D
Rationale: A peripheral IV catheter may be used for a vesicant if administration time is less than 60 minutes, a large vein is used, and there is careful monitoring of the IV site. B. Checking for patency and asking about discomfort at the IV site will help prevent an infiltration. C. IV pumps and alarms cannot be relied upon to detect extravasation because infiltration usually does not cause sufficient pressure to trigger an alarm. D. Checking for blood return in the central venous catheter prior to administration will help ensure that the medication is being administered into a vessel and not into tissues. E. Small-gauge syringes with small barrels produce high pressures and may cause injury to the blood vessel or may damage a central line catheter and should not be used.
The client is diagnosed with non-Hodgkin’s lymphoma. Which nursing concept should the nurse identify as priority?
- A. Immunity.
- B. Grieving.
- C. Perfusion.
- D. Clotting.
Correct Answer: A
Rationale: NHL impairs immunity (A) via lymph node dysfunction, increasing infection risk, a priority. Grieving (B), perfusion (C), and clotting (D) are secondary.
When reviewing the client’s medical record, the experienced nurse discovers that the client’s breast cancer is staged as T4 N3 M1. Which comment made by the experienced nurse to the new nurse is correct?
- A. “This client has a 3-cm breast tumor that has spread to only one lymph node.”
- B. “The TNM system is used to classify solid tumors by size and degree of spread.”
- C. “The higher the number in the TNM system, the better the chances are for a cure.”
- D. “This TNM system helps to classify tumors as either well- or poorly differentiated.”
Correct Answer: B
Rationale: A. The T4 N3 M1 indicates that the client’s primary tumor is very large, involves 3 lymph nodes, with distant metastasis (T is the size and extent and ranges from 1-4; N is number of nodes involved, and M1 indicates metastasis). B. This statement is correct. The tumor-node-metastasis (TNM) system classifies solid tumors by size and degree of spread. It is an international system that allows comparison of statistics among cancer centers. C. A higher number means that a more serious situation exists. D. A different rating system is used to define the cell types of tumors as well differentiated (closely resembles normal tissue) or poorly differentiated (tumor that contains some normal cells, but most cells are abnormal).
The client diagnosed with non-Hodgkin's lymphoma is scheduled for a lymphangiogram. Which information should the nurse teach?
- A. The scan will identify any malignancy in the vascular system.
- B. Radiopaque dye will be injected between the toes.
- C. The test will be done similar to a cardiac angiogram.
- D. The test will be completed in about five (5) minutes.
Correct Answer: B
Rationale: Lymphangiogram involves dye injection between toes (B) to visualize lymphatics. It’s not vascular (A), unlike cardiac angiogram (C), and takes longer than 5 minutes (D).