A client is scheduled to receive an IV dose of ondansetron eight hours after receiving chemotherapy. The client has peripheral IV (PIV) access and is sleeping quietly without any restlessness. The nurse caring for the client is not certified in chemotherapy administration. Which action should the nurse take?

Awaken the client to assess the need for administration of the ondansetron.

Ask a chemotherapy-certified nurse to administer the ondansetron.

Administer the ondansetron after flushing the PIV with 0.9% sodium chloride flush.

Hold the scheduled dose of ondansetron until the client awakens.

Answer and Explanation

The Correct Answer is C

Ondansetron is a selective 5-HT3 receptor antagonist utilized to mitigate chemotherapy-induced nausea and vomiting by blocking serotonin peripherally on vagal nerve terminals. Peak emetogenic risk occurs 0 to 24 hours post-treatment, necessitating prophylactic administration despite a resting state to maintain therapeutic serum levels and prevent acute gastric distress.

Rationale:

A. Assessing the need for a scheduled antiemetic is unnecessary as prophylactic dosing is standard clinical protocol for chemotherapy patients. Awakening the client disrupts essential restorative sleep cycles when the medication can be administered silently. Nurses prioritize maintaining a therapeutic steady-state to prevent breakthrough nausea before symptoms manifest.

B. Ondansetron is a supportive medication and does not require specialized certification for administration like cytotoxic agents. Any licensed nurse can manage peripheral access for non-vesicant, non-chemotherapeutic drugs. Requiring a certified nurse creates an unnecessary delay in care and inefficient utilization of specialized unit resources.

C. The nurse must verify cannula patency using a 0.9% sodium chloride flush before delivering the IV bolus. This action ensures the medication delivery is systemic and prevents complications like infiltration or extravasation. Proactive antiemetic therapy is a standard nursing intervention that does not require the client to be awake.

D. Holding the dose increases the risk of delayed emesis, which is much harder to control than preventing it. Maintaining the dosage schedule is critical even if the client appears comfortable or is currently sleeping. Delaying the drug could lead to metabolic imbalances or severe dehydration once the chemotherapy-induced nausea begins.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is []

Explanation

Brief introduction:

Respiratory failure in clients with underlying chronic obstructive pulmonary disease (COPD) or emphysema is a medical emergency that requires rapid assessment and intervention. When a client’s oxygen saturation drops significantly (75% on room air), they may develop acute encephalopathy due to cerebral hypoxia, leading to the sudden onset of confusion. Restoring oxygenation is the immediate priority to prevent further physiological deterioration and permanent organ damage.

Rationale for Correct Choices:

Obstructed airway: The client demonstrates severe hypoxia (SpO₂ 75% on room air), circumoral cyanosis, acute confusion, and removal/loss of the oxygen mask. Although he is breathing, his oxygenation is critically impaired, suggesting ineffective airway/oxygen delivery likely due to airway obstruction or failure of oxygen support in a COPD patient.
Replace the nonrebreather mask: The mask was found on the floor, meaning the client is not receiving prescribed high-flow oxygen. Immediate replacement is essential to restore oxygen delivery.
Use a manual bag valve mask (BVM) to provide breaths: The client is deteriorating neurologically (new confusion) with severe hypoxia. BVM ventilation provides immediate high-concentration oxygen and supports ventilation when nonrebreather therapy is ineffective or not being tolerated.
Level of consciousness: Mental status is a sensitive indicator of hypoxia. Improvement or further decline reflects effectiveness of oxygenation and ventilation.
Skin color: Cyanosis and pallor reflect oxygenation status. Improvement in color indicates improved tissue oxygen delivery.

Rationale for Incorrect Choices:

Hypoxia: Although the client is clearly hypoxic, hypoxia is a physiological state rather than the specific underlying problem choice. The question is asking for the most likely condition causing the deterioration, and among the provided options, obstructed airway best explains the sudden inability to maintain oxygenation with loss of the oxygen device.
Apnea: Apnea is the absence of breathing. This client has tachypnea (RR 29/min), so apnea is not consistent with the presentation.
Pulmonary edema: Pulmonary edema typically presents with crackles, pink frothy sputum, and severe fluid overload signs. These findings are not described, and the key issue here is loss of oxygen delivery with acute deterioration.
Increase the flow of oxygen to 12 L: Simply increasing flow is ineffective if the oxygen device is not properly applied or if ventilation is compromised. Airway and ventilation support take priority.
Perform oropharyngeal suction: There is no evidence of visible secretions, choking, or gurgling suggesting secretion obstruction. The priority is restoring oxygen delivery and ventilation, not suctioning.
Change the oxygen delivery method to nasal cannula: A nasal cannula provides significantly less oxygen than a nonrebreather mask and would worsen severe hypoxemia.
Pulse pressure: This reflects cardiovascular function and is not a reliable indicator of oxygenation or airway patency in this scenario.
Color and consistency of mucous: This is more relevant to infection or chronic respiratory assessment rather than acute life-threatening hypoxia.
Gag reflex: This is useful for aspiration risk or airway protection assessment but does not reflect immediate oxygenation status or response to treatment.

A. Suppression of aldosterone to prevent further sodium retention. B. Antidiuretic hormone (ADH) inhibition to promote water excretion and raise blood osmolarity. C. Aldosterone secretion causing sodium and water reabsorption and potassium excretion. D. Increased thirst triggered by antidiuretic hormone (ADH) and angiotensin II. E. Antidiuretic hormone (ADH) release increasing water reabsorption in the kidneys to dilute high plasma osmolarity. F. Natriuretic peptide release increasing urine output to reduce circulating blood volume.

Correct Answer is ["C","D","E"]

Explanation

Dehydration triggers the renin-angiotensin-aldosterone system (RAAS) and the release of vasopressin to restore circulatory homeostasis. When hypovolemia is sensed by baroreceptors and osmoreceptors, the body prioritizes renal water and sodium conservation to maintain mean arterial pressure. These mechanisms work synergistically to increase systemic vascular resistance and expand intravascular volume through targeted electrolyte and fluid shifts in the nephron.

Rationale:

A. Suppression of aldosterone would be a maladaptive response that worsens fluid volume deficit. In dehydration, the body actually increases aldosterone levels to stimulate sodium conservation, which helps pull water back into the vascular space. Reducing this hormone would lead to further hypotension and circulatory collapse.

B. Inhibition of antidiuretic hormone would result in excessive diuresis, which is the opposite of the desired homeostatic response. High plasma osmolarity and decreased blood volume are the primary triggers for ADH release, not inhibition. Proper hormone function ensures the kidneys produce concentrated urine to preserve total body water.

C. Aldosterone acts on the distal tubules and collecting ducts to facilitate sodium reabsorption, which facilitates passive water retention. This hormone also promotes potassium excretion as an exchange ion, helping to stabilize blood pressure during dehydration. It is a critical component of the long-term regulation of extracellular fluid volume.

D. Angiotensin II and antidiuretic hormone act on the hypothalamus to stimulate the thirst mechanism, encouraging increased oral intake. This behavioral response is essential for replacing intracellular fluid lost during prolonged vomiting and diarrhea. Combined with renal conservation, thirst helps restore the equilibrium of bodily fluids.

E. Antidiuretic hormone is released in response to high plasma osmolarity to increase the permeability of the collecting ducts. This allows for significant free water reabsorption, which helps dilute the blood and increase the circulating volume. It is the body's primary defense against hypertonicity during acute fluid loss.

F. Natriuretic peptides are released during fluid overload when the heart atria are stretched, not during dehydration. These peptides promote natriuresis and diuresis, which would be extremely dangerous for a hypotensive client. The body must suppress these peptides to prevent further circulatory volume depletion.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

A client is admitted with hypotension, tachycardia, low urine output, and dry mucous membranes after severe vomiting and diarrhea. Laboratory results indicate dehydration. Which hormone-driven response(s) should the nurse expect? Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare?

The nurse is providing discharge instructions to a client with atopic dermatitis who received a prescription for dexamethasone 8 mg PO daily. Which symptom should the nurse explain is most important for the client to report to the healthcare provider?

A young school-age child with a history of a waddling gait and frequent falls is brought into the hospital for diagnostic testing. When explaining the diagnostic testing to the parents, the nurse should provide information based on which understanding of the underlying disease pathology?

A client has a nasogastric tube (NGT) inserted for intermittent enteral feedings. Which action(s) should the nurse take before administering a feeding? Select all that apply.

Patient Data Which additional question(s) could help the nurse create the client's nutritional education plan? Select all that apply.

While caring for a client's postoperative dressing, the nurse observes purulent wound drainage. Previously, the wound was inflamed and tender but without drainage. Which is the most important action for the nurse to take?