A client's morning assessment includes bounding peripheral pulses, weight gain of 2 pounds (0.91 kg), pitting ankle edema, and moist crackles bilaterally. Which intervention is most important for the nurse to include in this client's plan of care?

Administer prescribed diuretic.

Maintain accurate intake and output.

Weigh client every morning.

Restrict daily fluid intake to 1500 mL.

Answer and Explanation

The Correct Answer is A

A. Administering a prescribed diuretic is the most important intervention because the client is showing signs of fluid volume overload, including bounding peripheral pulses, rapid weight gain, pitting edema, and bilateral lung crackles. Diuretics help remove excess fluid, reduce edema, improve cardiac output, and relieve pulmonary congestion. Prompt administration addresses the immediate risk of worsening heart failure or respiratory compromise.

B. Maintaining accurate intake and output is essential for ongoing monitoring of fluid status, but it does not provide immediate relief of fluid overload. It is supportive but secondary to active treatment with a diuretic.

C. Weighing the client every morning is important for tracking fluid retention over time. However, daily weight monitoring is a preventive and monitoring strategy, not an immediate therapeutic intervention for acute fluid overload.

D. Restricting daily fluid intake may help prevent further fluid accumulation, but it does not remove the excess fluid already present. Fluid restriction is a secondary measure that complements diuretic therapy but does not address the immediate risk posed by pulmonary congestion and edema.

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Correct Answer is C

Explanation

A. Mitotic inhibitors, such as vincristine and paclitaxel, work by inhibiting microtubule formation during cell division. Dactinomycin does not function through this mechanism, so it does not belong to this class.

B. Corticosteroids, like prednisone or dexamethasone, are anti-inflammatory and immunosuppressive agents. Dactinomycin is not a corticosteroid and does not have these effects.

C. Antitumor antibiotics, such as dactinomycin, act by binding to DNA and inhibiting RNA synthesis, thereby preventing cancer cell replication. Dactinomycin is specifically used in pediatric cancers, including Wilms tumor and rhabdomyosarcoma, as part of combination chemotherapy protocols.

D. Alkylating agents, such as cyclophosphamide or ifosfamide, work by adding alkyl groups to DNA, causing cross-linking and DNA damage. Dactinomycin does not exert its effects through alkylation and is not classified as an alkylating agent.

A. 18 to 21 gauge needle. B. 1 inch needle. C. 23 to 25 gauge needle. D. Sterile gloves. E. 5/8 inch needle.

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

Explanation

A. An 18 to 21 gauge needle is appropriate for administering viscous or oil-based medications intramuscularly. IM injections require delivery of the medication into the muscle tissue, which can sometimes necessitate a larger bore needle depending on the medication’s viscosity. Using the correct gauge ensures that the medication is delivered properly and prevents issues like clogging or tissue trauma.

B. A 1-inch needle is commonly used for average-weight adults, but for a client weighing 200 pounds (90 kg), the subcutaneous tissue may be thicker, particularly in areas like the deltoid or gluteal region. To ensure the medication reaches the muscle, a longer needle (e.g., 1.5 inches) is often required. Using a 1-inch needle may result in the medication being deposited in subcutaneous fat instead of muscle, which can reduce absorption and effectiveness.

C. A 23 to 25 gauge needle is commonly used for most IM injections that are not highly viscous. This gauge is suitable for delivering standard medications like vaccines or antibiotics with minimal discomfort while still ensuring intramuscular delivery. Nurses may select the gauge based on medication type, injection site, and patient comfort.

D. Sterile gloves are required to maintain aseptic technique and reduce the risk of introducing infection into the injection site. Gloves also protect the nurse from exposure to blood or body fluids and are standard practice for all parenteral procedures.

E. A 5/8 inch needle is designed for subcutaneous injections and is too short to reach the muscle layer in an adult, especially in clients with higher body weight. Using a needle of this length for an IM injection would risk depositing the medication in subcutaneous tissue rather than the muscle, which could impair absorption and effectiveness and potentially cause local irritation.

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Medication	Drug Classification	Treatment Goals
Furosemide	_______________	_______________
Digoxin	_______________	_______________
Captopril	_______________	_______________

A client's morning assessment includes bounding peripheral pulses, weight gain of 2 pounds (0.91 kg), pitting ankle edema, and moist crackles bilaterally. Which intervention is most important for the nurse to include in this client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A child diagnosed with Wilms tumor is receiving dactinomycin as part of their treatment. To which drug classification does dactinomycin belong?

Correct Answer is C

Explanation

The nurse is preparing to administer an IM injection to an adult client who weighs 200 pounds (90 kg). Which equipment is needed for this procedure? Select all that apply.

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

Explanation

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