A client, who is receiving intravenous chemotherapy into a peripheral vein, says that the arm burns terribly in and around the intravenous site. What is the nurse's best first action?

Slow the rate of infusion

Apply a warm compress to the site

Discontinue the infusion

Check for blood return

Answer and Explanation

The Correct Answer is C

A. Slowing the rate of infusion may provide some temporary relief, but it does not address the underlying issue and may worsen the situation.
B. Applying a warm compress may soothe discomfort but is not the priority action when a burning sensation is reported, which could indicate potential extravasation.
C. Discontinuing the infusion is the best first action to prevent further damage to the tissue and to assess for complications such as infiltration or extravasation.
D. Checking for blood return can help assess the patency of the IV line, but the priority is to stop the infusion immediately to prevent complications.

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Correct Answer is C

Explanation

A. A history of Roux-en-Y gastric bypass surgery is not a direct risk factor for colorectal cancer; in some cases, it may reduce risk due to weight loss and dietary changes.
B. A high fiber, low fat diet is considered protective against colorectal cancer rather than a risk factor.
C. A personal history of inflammatory bowel disease, such as ulcerative colitis or Crohn's disease, significantly increases the risk for developing colorectal cancer due to chronic inflammation and cellular changes in the colon.
D. Having a distant relative with colorectal cancer may increase risk, but the personal history of inflammatory bowel disease is a stronger risk factor warranting emphasis in teaching.

A. Encourage client to rinse the mouth twice a day with mouthwash B. Encourage client to perform mouth care before and after every meal C. Offer the client 3 meals per day with a snack at bedtime D. Assess the client's oral pain level once a shift

Correct Answer is B

Explanation

A. Rinsing the mouth with mouthwash is not sufficient for managing oral lesions, and some mouthwashes may contain alcohol that can further irritate the lesions; therefore, this intervention is inadequate.
B. Performing mouth care before and after every meal can help minimize discomfort, remove debris, and maintain oral hygiene, which is crucial for someone with painful oral lesions to encourage better nutritional intake.
C. Offering three meals with a bedtime snack may not be effective if the client is unable to eat comfortably; focusing on smaller, more frequent meals or nutrient-dense options may be more beneficial.
D. While assessing oral pain is important, it should occur more frequently than once per shift to ensure ongoing management and adjustment of care based on the client’s comfort and needs.

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A client, who is receiving intravenous chemotherapy into a peripheral vein, says that the arm burns terribly in and around the intravenous site. What is the nurse's best first action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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