A client with cancer is receiving chemotherapy with a known vesicant. The client's IV has been in place for 72 hours. The nurse determines that a new IV site cannot be obtained, and leaves the present IV in place. Which is the greatest clinical risk related to this situation?
Peripheral neurovascular dysfunction.
Impaired skin integrity.
Fluid volume excess.
Acute pain and anxiety.
The Correct Answer is B
A. Peripheral neurovascular dysfunction. While some chemotherapy agents can cause neuropathy, the immediate risk of a vesicant (a drug that can cause severe tissue damage if it leaks) is extravasation, leading to skin and tissue damage, rather than direct neurovascular impairment.
B. Impaired skin integrity. Vesicants can cause severe tissue necrosis if they extravasate (leak into surrounding tissues). Leaving an IV in place for 72 hours increases the risk of infiltration or extravasation, which can lead to serious complications, including blistering, necrosis, and deep tissue injury. Proper IV site rotation and monitoring are essential to prevent skin and tissue damage.
C. Fluid volume excess. Fluid volume excess is not a direct risk related to vesicant chemotherapy. While some IV fluids can contribute to fluid overload, the primary concern with vesicants is extravasation and tissue damage.
D. Acute pain and anxiety. While pain and anxiety can occur if extravasation happens, the greatest clinical risk is the physical damage caused by tissue necrosis. Pain is a symptom of extravasation, but preventing skin and tissue injury is the priority.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Dedicated breastfeeding for 6 months. Exclusive breastfeeding for at least 6 months is recommended by the American Academy of Pediatrics (AAP) and is associated with a lower risk of childhood obesity. Breastfeeding helps regulate appetite and metabolism.
B. Consumption of whole milk as a toddler. Whole milk is recommended from ages 1 to 2 years for brain development and growth. While excessive milk intake may contribute to weight gain, it is not a primary risk factor for early childhood obesity.
C. Introduction of fortified cereal before 4 months of age. Introducing solid foods before 4 months is linked to an increased risk of childhood obesity. Early introduction may disrupt natural hunger and satiety cues, leading to overeating later in life. The AAP recommends introducing solid foods around 6 months of age.
D. Exclusive soy-based formula for the first year of life. Soy-based formula is nutritionally comparable to cow's milk-based formula. While formula feeding in general has been associated with a slightly higher risk of obesity than breastfeeding, soy formula itself is not a direct risk factor for obesity.
Correct Answer is A
Explanation
A. Thyroxine (T4). Congenital hypothyroidism is diagnosed by measuring low levels of thyroxine (T4) and elevated thyroid-stimulating hormone (TSH). Infants with hypothyroidism have delayed metabolism, poor growth, and developmental delays. Reporting low T4 levels is critical for early treatment with levothyroxine to prevent intellectual disability and growth impairment.
B. Growth hormone (GH) levels. While GH is important for growth, it is not the primary diagnostic test for congenital hypothyroidism. GH deficiency is a separate endocrine disorder.
C. Follicle-stimulating hormone (FSH) levels. FSH is involved in reproductive development and is not relevant for diagnosing hypothyroidism in an infant.
D. Luteinizing hormone (LH) levels. LH plays a role in pubertal development and reproductive function, but it is not used to diagnose congenital hypothyroidism.
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