Nokea
The nurse is administering an intravenous vesicant chemotherapeutic agent to a client. Which assessment would require the nurse's immediate action?
- A. Stomatitis lesion in the mouth
- B. Severe nausea and vomiting
- C. Complaints of pain at site of infusion
- D. A rash on the client's extremities
Correct Answer: C
Rationale: Complaints of pain at site of infusion. A vesicant is a chemotherapeutic agent capable of causing blistering of tissues and possible tissue necrosis if there is extravasation. These agents are irritants which cause pain along the vein wall, with or without inflammation.
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The 68-year-old client is admitted to the emergency department with complaints of slurred speech, right-sided weakness, and ataxia. The emergency department physician ordered thrombolytic therapy for the client. Which action should the nurse implement first?
- A. Administer thrombolytic therapy via protocol.
- B. Send the client for a STAT CT of the head.
- C. Arrange for admission to the intensive care department.
- D. Check to determine if the client is cross sensitive to the thrombolytic.
Correct Answer: B
Rationale: A STAT head CT rules out hemorrhagic stroke, a contraindication for thrombolytics, and is the first step per stroke guidelines.
A post-operative client has a prescription for acetaminophen with codeine. What should the nurse recognize as a primary effect of this combination?
- A. Enhanced pain relief
- B. Minimized side effects
- C. Prevention of drug tolerance
- D. Increased onset of action
Correct Answer: A
Rationale: Enhanced pain relief. Combination of analgesics with different mechanisms of action can afford greater pain relief.
An adult has angina and is to be discharged on transdermal nitroglycerin. Which statement by the client indicates that the client needs additional teaching?
- A. I am glad that I can continue walking.
- B. I will change the site each day.
- C. I will be able to continue to drink alcoholic beverages.
- D. I will need to get up slowly.
Correct Answer: C
Rationale: Alcohol can enhance nitroglycerin’s hypotensive effects, increasing the risk of dizziness or fainting, requiring avoidance.
The nurse is hanging 1,000 mL of IV fluids to run for eight (8) hours. The intravenous tubing is a microdrip. How many gtt/min should the IV rate be set?
Correct Answer: 15
Rationale: Microdrip is 60 gtt/mL. Rate: (1,000 mL / 8 hr) x (60 gtt/mL / 60 min) = 125 mL/hr x 1 gtt/min = 15.625 gtt/min, rounded to 15 gtt/min.
The client with type 2 diabetes is diagnosed with gout and prescribed allopurinol (Zyloprim). Which instruction should the nurse discuss when teaching about this medication?
- A. The client will probably develop a red rash on the body.
- B. The client should drink two (2) to three (3) liters of water a day.
- C. The client should take this medication on an empty stomach.
- D. The client will need to increase oral diabetic medications.
Correct Answer: B
Rationale: Allopurinol increases uric acid excretion, risking kidney stones; 2–3 L water daily prevents this. Rash is possible but not probable, stomach timing is flexible, and diabetes meds are unaffected.