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What action should the healthcare provider take to reduce the risk of vesicant extravasation in a client receiving intravenous chemotherapy?
- A. Administer an antiemetic before starting the chemotherapy.
- B. Instruct the client to drink plenty of fluids during the treatment.
- C. Keep the head of the bed elevated until the treatment is completed.
- D. Monitor the client's intravenous site hourly during the treatment.
Correct Answer: D
Rationale: The correct answer is D: Monitor the client's intravenous site hourly during the treatment. This is crucial to reduce the risk of vesicant extravasation, which can cause tissue damage if the chemotherapy leaks into the surrounding tissues. By monitoring the IV site hourly, the healthcare provider can detect any signs of infiltration or extravasation early and take necessary actions to prevent further harm.
A: Administering an antiemetic before starting chemotherapy is unrelated to preventing vesicant extravasation.
B: Instructing the client to drink plenty of fluids does not directly address the risk of vesicant extravasation.
C: Keeping the head of the bed elevated is not specific to preventing vesicant extravasation and may not effectively reduce the risk.
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When a client expresses, 'I don't know how I will go on' while discussing feelings related to a recent loss, the nurse remains silent. What is the most likely reason for the nurse's behavior?
- A. The nurse is indicating disapproval of the statement.
- B. The nurse is showing respect for the client's loss.
- C. Silence is mirroring the client's sadness.
- D. Silence enables the client to contemplate what was expressed.
Correct Answer: D
Rationale: The correct answer is D because the nurse's silence allows the client to reflect on and process their emotions after expressing uncertainty about the future. By remaining silent, the nurse gives the client space to explore their feelings and thoughts without interruption. This can help the client gain insight and come to terms with their emotions.
A: The nurse's silence does not indicate disapproval, as it is a common therapeutic technique.
B: While the nurse may be showing respect for the client's loss, the primary reason for the silence is to facilitate the client's reflection.
C: Although silence can sometimes mirror the client's emotions, the main purpose here is to enable contemplation rather than direct mirroring.
A client with myelogenous leukemia is receiving an autologous bone marrow transplantation (BMT). What is the priority intervention that the nurse should implement when the bone marrow is repopulating?
- A. Administer sargramostim (Leukine, Prokine).
- B. Infuse PRBC and platelet transfusions.
- C. Give parenteral prophylactic antibiotics.
- D. Maintain a protective isolation environment.
Correct Answer: D
Rationale: The correct answer is D: Maintain a protective isolation environment. During bone marrow repopulation after transplantation, the client is at high risk of infection due to compromised immune function. By maintaining a protective isolation environment, the nurse can minimize the risk of exposure to pathogens that could lead to infections. This intervention helps prevent potential complications and supports the client's recovery.
Rationale for other choices:
A: Administering sargramostim may enhance white blood cell production but does not directly address the risk of infection during bone marrow repopulation.
B: Infusing PRBC and platelet transfusions may be necessary for managing anemia and thrombocytopenia but does not address the priority of infection prevention.
C: Giving prophylactic antibiotics may be beneficial in some cases, but maintaining a protective isolation environment is the priority to reduce the risk of infection in this immunocompromised client.
A client with hypothyroidism is started on levothyroxine (Synthroid). Which statement by the client indicates a need for further teaching?
- A. I will take this medication every morning before breakfast.
- B. I should have my thyroid levels checked regularly.
- C. If I lose weight, I may need an increased dose.
- D. I can stop taking this medication once my symptoms improve.
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Levothyroxine is a lifelong medication for hypothyroidism.
2. Stopping medication prematurely can lead to symptom relapse.
3. Symptoms improving doesn't indicate the underlying condition is resolved.
4. Regular monitoring and dose adjustments are crucial.
5. Choice D shows misunderstanding of treatment duration and necessity.
Summary:
A: Correct, taking in the morning maximizes absorption.
B: Correct, monitoring is necessary for dose adjustments.
C: Correct, weight loss can affect thyroid hormone levels.
D: Incorrect, as stopping medication prematurely is not advised.
An elderly client with congestive heart failure (CHF) is admitted to the hospital. Which laboratory test result should the nurse expect to find?
- A. Elevated serum sodium level.
- B. Decreased brain natriuretic peptide (BNP) level.
- C. Increased serum creatinine level.
- D. Elevated hemoglobin and hematocrit levels.
Correct Answer: C
Rationale: The correct answer is C, increased serum creatinine level. In CHF, the heart's reduced pumping ability can lead to decreased blood flow to the kidneys, resulting in impaired kidney function. This can cause an elevation in serum creatinine level, indicating decreased kidney function. Elevated serum sodium level (A) is not typically seen in CHF, as patients often have fluid retention leading to dilutional hyponatremia. Decreased BNP level (B) is not expected in CHF, as BNP is released in response to increased ventricular stretching and volume overload. Elevated hemoglobin and hematocrit levels (D) are not directly related to CHF; they may be seen in conditions like dehydration or chronic hypoxia, but not specifically in CHF.
The healthcare provider is caring for a client with a chest tube. Which assessment finding requires immediate intervention?
- A. Intermittent bubbling in the water seal chamber.
- B. Drainage of 75 ml in the first hour post-insertion.
- C. Crepitus around the insertion site.
- D. Fluctuation of the water level in the water seal chamber with respiration.
Correct Answer: C
Rationale: The correct answer is C: Crepitus around the insertion site. Crepitus suggests subcutaneous emphysema, which can indicate a pneumothorax or air leak. Immediate intervention is needed to prevent further complications.
A: Intermittent bubbling in the water seal chamber is expected and indicates a functioning chest tube system.
B: Drainage of 75 ml in the first hour post-insertion is within the normal range and should be monitored.
D: Fluctuation of the water level in the water seal chamber with respiration is a normal finding indicating the chest tube is functioning correctly.