Nokea
You are the nurse caring for a patient who is to receive IV daunorubicin, a chemotherapeutic agent. You start the
infusion and check the insertion site as per protocol. During your most recent check, you note that the IV has infiltrated
so you stop the infusion. What is your main concern with this infiltration?
- A. Extravasation of the medication
- B. Discomfort to the patient
- C. Blanching at the site
- D. Hypersensitivity reaction to the medication
Correct Answer: A
Rationale: The correct answer is A: Extravasation of the medication. Extravasation occurs when the infused medication leaks into surrounding tissues, potentially causing tissue damage and necrosis. This is a serious concern with vesicant medications like daunorubicin. If left untreated, it can lead to severe complications.
Choice B: Discomfort to the patient is incorrect because while discomfort may occur with infiltration, the main concern is the potential for tissue damage from extravasation.
Choice C: Blanching at the site is incorrect as it is a common sign of infiltration, but the main concern is the possibility of extravasation and tissue damage.
Choice D: Hypersensitivity reaction to the medication is incorrect as it is a different type of reaction that is not directly related to infiltration or extravasation.
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A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first?
- A. Assess the client's dietary intake of foods high in potassium.
- B. Assess the client's neuromuscular status.
- C. Assess the client's fluid intake and output.
- D. Read food labels to determine sodium content.
Correct Answer: D
Rationale: The correct answer is D: Read food labels to determine sodium content. The nurse should assess the client's sodium level of 144 mEq/L, which is slightly above the normal range. High sodium intake can lead to fluid retention, hypertension, and other health issues. By reading food labels to determine sodium content, the nurse can identify sources of high sodium intake in the client's diet and provide appropriate dietary recommendations. This assessment is crucial in managing the client's sodium levels and overall health.
Assessing the client's dietary intake of foods high in potassium (Choice A) is not the priority in this case since the client's potassium level is within the normal range. Assessing the client's neuromuscular status (Choice B) is important but not the first priority when considering the electrolyte imbalances present. Assessing the client's fluid intake and output (Choice C) is also important but does not address the immediate concern related to the client's elevated sodium level.
The nurse is preparing to insert a peripheral IV catheter into a patient who will require fluids and IV antibiotics.
How should the nurse always start the process of insertion?
- A. Leave one hand ungloved to assess the site.
- B. Cleanse the skin with normal saline.
- C. Ask the patient about allergies to latex or iodine.
- D. Remove excessive hair from the selected site.
Correct Answer: C
Rationale: Correct Answer: C
Rationale: Asking the patient about allergies to latex or iodine is crucial before starting the IV insertion process. This step ensures patient safety and prevents potential allergic reactions. Knowing the patient's allergies allows the nurse to select appropriate materials for the procedure, reducing the risk of complications.
Summary of Other Choices:
A: Leaving one hand ungloved is not recommended as it compromises infection control practices.
B: Cleansing the skin with normal saline is important but should come after confirming allergies to latex or iodine.
D: Removing excessive hair from the site is unnecessary and not a standard practice for starting the IV insertion process.
You are the nurse evaluating a newly admitted patients laboratory results, which include several values that are
outside of reference ranges. Which of the following would cause the release of antidiuretic hormone (ADH)?
- A. Increased serum sodium
- B. Decreased serum potassium
- C. Decreased hemoglobin
- D. Increased platelets
Correct Answer: A
Rationale: The correct answer is A: Increased serum sodium. High serum sodium levels trigger the release of antidiuretic hormone (ADH) from the pituitary gland to help retain water in the body and maintain fluid balance. This is a physiological response to prevent further dehydration. Decreased serum potassium (choice B), decreased hemoglobin (choice C), and increased platelets (choice D) do not directly stimulate the release of ADH. Hence, they are incorrect choices in this scenario.
A nurse is planning care for a client who is hyperventilating. The clients arterial blood gas values are pH 7.30, PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3 26 mEq/L. Which question should the nurse ask when developing this clients plan of care?
- A. Do you take any over-the-counter medications?
- B. You appear anxious. What is causing your distress?
- C. Do you have a history of anxiety attacks?
- D. You are breathing fast. Is this causing you to feel light-headed?
Correct Answer: B
Rationale: The correct answer is B: "You appear anxious. What is causing your distress?" because hyperventilation can be triggered by emotional distress or anxiety. By addressing the underlying cause of the hyperventilation, the nurse can provide appropriate interventions to help the client manage their anxiety and subsequently reduce the hyperventilation episodes.
A: "Do you take any over-the-counter medications?" - This question is not directly related to addressing the client's anxiety or distress, which is the primary concern in hyperventilation.
C: "Do you have a history of anxiety attacks?" - While relevant to understanding the client's medical history, this question does not address the immediate cause of hyperventilation in this specific situation.
D: "You are breathing fast. Is this causing you to feel light-headed?" - This question focuses on the physical symptoms of hyperventilation rather than exploring the emotional or psychological triggers, which are essential in managing hyperventilation caused by anxiety.
The nurse is providing care for a patient with chronic obstructive pulmonary disease. When describing the process of
respiration the nurse explains how oxygen and carbon dioxide are exchanged between the pulmonary capillaries and the
alveoli. The nurse is describing what process?
- A. Diffusion
- B. Osmosis
- C. Active transport
- D. Filtration
Correct Answer: A
Rationale: The correct answer is A: Diffusion. In respiration, oxygen and carbon dioxide are exchanged between the alveoli and pulmonary capillaries through the process of diffusion. Here's the rationale:
1. Diffusion is the movement of molecules from an area of high concentration to an area of low concentration.
2. In the alveoli, oxygen moves from the air (higher concentration) into the blood (lower concentration) and carbon dioxide moves from the blood (higher concentration) into the air (lower concentration).
3. This exchange occurs passively, without the need for energy input, which is characteristic of diffusion.
Summary of other choices:
B: Osmosis involves the movement of water across a semi-permeable membrane, not gas exchange.
C: Active transport requires energy input to move molecules against their concentration gradient, not seen in gas exchange.
D: Filtration involves the movement of molecules through a membrane under pressure, not the passive movement of gases in respiration.