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While a patient is receiving IV doxorubicin hydrochloride for the treatment of cancer, the nurse observes swelling and pain at the IV site. The nurse should prioritize what action?
- A. Stopping the administration of the drug immediately
- B. Notifying the patients physician
- C. Continuing the infusion but decreasing the rate
- D. Applying a warm compress to the infusion site .
Correct Answer: A
Rationale: Swelling and pain at the IV site can indicate extravasation, which is the leakage of a vesicant medication like doxorubicin hydrochloride into the surrounding tissues. It is crucial to stop the administration of the drug immediately upon suspicion of extravasation to minimize tissue damage and potential complications. By stopping the administration promptly, further harm can be prevented, and early interventions can be initiated to mitigate the effects of the extravasation. Notifications to the physician and appropriate actions, such as aspiration of any remaining drug, may follow after discontinuing the infusion.
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The nurse is providing health education to the parents of a toddler who has been diagnosed with food allergies. What should the nurse teach this family about the childs health problem?
- A. Food allergies are a life-long condition, but most families adjust quite well to the necessary lifestyle changes.
- B. Consistent use of over-the-counter antihistamines can often help a child overcome food allergies.
- C. Make sure that you carry a steroid inhaler with you at all times, especially when you eat in restaurants.
- D. Many children outgrow their food allergies in a few years if they avoid the offending foods.
Correct Answer: A
Rationale: Food allergies are a serious health concern that can have life-threatening consequences if not managed properly. It is important for the nurse to educate the family that food allergies are typically life-long conditions and cannot be fully cured. While some children may outgrow certain food allergies over time, it is not guaranteed for all cases. Therefore, the focus should be on effectively managing the allergy through avoidance of trigger foods, carrying emergency medications like epinephrine auto-injectors, and being prepared to respond to allergic reactions. Adjusting to the necessary lifestyle changes, such as reading food labels, informing others about the child's allergies, and being vigilant about potential allergen exposure, is essential for ensuring the child's safety and well-being. Consistent monitoring and communication with healthcare providers are also crucial components of managing food allergies on a long-term basis.
A patient comes to the clinic complaining of a tender, inflamed vulva. Testing does not reveal the presence of any known causative microorganism. What aspect of this patients current health status may account for the patients symptoms of vulvitis?
- A. The patient is morbidly obese.
- B. The patient has type 1 diabetes.
- C. The patient has chronic kidney disease.
- D. The patient has numerous allergies.
Correct Answer: A
Rationale: Morbid obesity is a risk factor for developing a condition known as intertrigo, which is inflammation of the skin folds. In this case, the skin folds of the vulva are affected, leading to vulvitis. The warm and moist environment between the skin folds in obese individuals can promote the growth of microorganisms and the development of inflammation. This can result in symptoms such as tenderness and redness in the vulva. Since testing did not reveal the presence of any known causative microorganism, the patient's morbid obesity may be the underlying factor contributing to the symptoms of vulvitis. Treating the intertrigo and addressing the underlying obesity may help alleviate the symptoms.
A nurse is caring for a patient who has allergic rhinitis. What intervention would be most likely to help the patient meet the goal of improved breathing pattern?
- A. Teach the patient to take deep breaths and cough frequently.
- B. Use antihistamines daily throughout the year.
- C. Teach the patient to seek medical attention at the first sign of an allergic reaction.
- D. Modify the environment to reduce the severity of allergic symptoms.
Correct Answer: D
Rationale: Allergic rhinitis, also known as hay fever, is a condition characterized by inflammation in the nasal passages triggered by allergens such as pollen, dust mites, or animal dander. Modifying the patient's environment to reduce exposure to these allergens can significantly help improve the breathing pattern in patients with allergic rhinitis. This can include measures such as using air purifiers, keeping indoor humidity levels low, avoiding exposure to pollen by keeping windows closed during peak seasons, and regularly cleaning bedding to reduce dust mites.
The nurse is caring for a patient who has undergone a mastoidectomy. In an effort to prevent postoperative infection, what intervention should the nurse implement?
- A. Teach the patient about the risks of ototoxic medications.
- B. Instruct the patient to protect the ear from water for several weeks.
- C. Teach the patient to remove cerumen safely at least once per week.
- D. Instruct the patient to protect the ear from temperature extremes until healing is complete.
Correct Answer: B
Rationale: After a mastoidectomy, the ear should be protected from water for several weeks. This is because exposing the area to water can increase the risk of infection. Keeping the ear dry allows the surgical site to heal properly and reduces the likelihood of postoperative complications such as infection. Therefore, instructing the patient to protect the ear from water is an important intervention to prevent postoperative infection following a mastoidectomy.
The nurse responds to the call light of a patient who has had a cervical diskectomy earlier in the day. Thecpatient states that she is having severe pain that had a sudden onset. What is the nurses most appropriate action?
- A. Palpate the surgical site.
- B. Remove the dressing to assess the surgical site.
- C. Call the surgeon to report the patients pain.
- D. Administer a dose of an NSAID.
Correct Answer: C
Rationale: In this scenario, the patient who has had a cervical diskectomy is experiencing severe pain with a sudden onset, which can be indicative of a complication such as bleeding, infection, or nerve impingement. The nurse's most appropriate action is to call the surgeon immediately to report the patient's pain. The surgeon needs to be informed promptly so that a further assessment can be made and appropriate interventions can be initiated to address the cause of the sudden pain. Palpating the surgical site or removing the dressing without consulting the surgeon first may worsen the situation or increase the risk of complications. Administering an NSAID is not appropriate in this situation without further evaluation and guidance from the surgeon. It is essential to prioritize patient safety and ensure that the patient receives timely and appropriate care by involving the surgeon in the decision-making process.