Nokea
Which of the following clients is at greatest risk for extravasation?
- A. The client with heart failure who is receiving Ringer's lactate
- B. The client with cancer who is receiving bendamustine
- C. The client who is receiving potassium supplementation intravenously
- D. The client who is receiving total parenteral nutrition
Correct Answer: B
Rationale: Bendamustine, a chemotherapy drug, is a vesicant, posing a high risk for extravasation, which can cause severe tissue damage if it leaks into surrounding tissues.
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A hospitalized client fell on the floor and sustained a small laceration on her hand that required stitches. The intern will suture the client's hand at the client's bedside and asks for bupivacaine (Marcaine) with epinephrine and a suture kit in order to suture the laceration. The nurse should question which of the following?
- A. The intern's ability to suture.
- B. The client's room as an aseptic environment.
- C. Marcaine with epinephrine as the local anesthetic.
- D. The cosmetic effect from not having a plastic surgeon do the suturing.
Correct Answer: C
Rationale: Bupivacaine with epinephrine should be questioned for hand lacerations, as epinephrine can cause vasoconstriction and potential tissue ischemia in extremities.
The nurse is caring for a client with a history of breast cancer who is receiving chemotherapy. Which of the following laboratory values should the nurse monitor closely?
- A. White blood cell count.
- B. Blood glucose levels.
- C. Serum potassium.
- D. Hemoglobin A1c.
Correct Answer: A
Rationale: Chemotherapy can cause bone marrow suppression, requiring close monitoring of white blood cell counts for infection risk.
The nurse evaluates the arterial blood gas (ABG) results of a client who is receiving supplemental oxygen. Which Po2 finding would indicate that the oxygen level was adequate?
- A. 45 mm Hg
- B. 50 mm Hg
- C. 60 mm Hg
- D. 80 mm Hg
Correct Answer: D
Rationale: The normal Po2 level is 80 to 100 mm Hg. The remaining options are low values and do not indicate adequate oxygen levels.
After several months of taking olanzapine (Zyprexa), the client reports that he is no longer hearing voices of any kind. Which of the following would confirm that the client is developing insight into his illness?
- A. That Zyprexa is the best medicine I have ever had.'
- B. I didn't realize how sick I could get from a chemical brain imbalance.'
- C. My mom is proud of me for staying on my medicines.'
- D. I think I may be able to get a little part-time job soon.'
Correct Answer: B
Rationale: Acknowledging a chemical brain imbalance shows insight into the biological basis of the illness, indicating understanding of the need for treatment.
As the nurse in a primary care clinic, which cultural concern would you integrate into your psychological assessments of your clients?
- A. The concern related to the client's cultural reluctance to report psychological symptoms because of some possible culturally based stigma associated with psychiatric mental health disorders
- B. Concerns revolving around the lack of financial and health insurance resources to pay for psychological care
- C. Concerns related to the compliance with psychological treatment regimens because of the client's lack of social support systems
- D. The concern related to the culturally based client apathy about nursing care and nursing assessments
Correct Answer: A
Rationale: Cultural stigma around mental health can significantly impact clients' willingness to report psychological symptoms, making it a critical consideration in assessments.