A nurse is caring for a 63-year-old female client in the emergency department (ED) with a history of colorectal cancer. The client is receiving chemotherapy and radiation. She presents with complaints of fatigue, unexplained bruising, and recurring headaches. The nurse must evaluate the situation based on the exhibits provided to determine the client’s risk factors and findings.

Exhibits

The client is at risk for developing
dropdown
due to their
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Choice A rationale:

The client's low platelet count (90 x 10⁹/L) is a significant risk factor for developing Disseminated Intravascular Coagulation (DIC), a condition characterized by abnormal blood clotting and bleeding. The client's history of cancer and symptoms such as unexplained bruising and fatigue further support this risk.

Choice B rationale:

Hyperkalemia is characterized by high potassium levels, but the client's potassium level is within the normal range (4.1 mmol/L), so this is not a risk factor.

Choice C rationale:

Hyponatremia is a condition of low sodium levels in the blood. The client's sodium level is normal (137 mmol/L), so this is not a risk factor.

Choice D rationale:

Pneumonia is a lung infection, and the client's oxygen saturation is normal (98% on room air), indicating no immediate risk of pneumonia.

Choice E rationale:

Acute nephritic syndrome is a kidney disorder that can cause elevated blood urea nitrogen (BUN) and creatinine levels. The client's BUN is slightly elevated (22 mg/dL), but her creatinine level is normal (1.0 mg/dL), making this less likely.

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Correct Answer is ["A","B","E"]

Explanation

Choice A rationale
Resistance to the flow of IV fluid may indicate infiltration or extravasation, where the medication leaks into surrounding tissues, necessitating stopping the infusion.
Choice B rationale
Burning or pain, swelling, or redness at the site are signs of extravasation, which is a serious complication of vincristine administration and requires immediate action.
Choice C rationale
Reporting anxiety and depression are not directly related to vincristine infusion site complications. These are more systemic effects and do not indicate the need to stop the infusion immediately.
Choice D rationale
Nausea and vomiting are common side effects of vincristine but do not indicate a problem with the IV line itself, so they do not require stopping the infusion.
Choice E rationale
Absence of blood return from the IV catheter may indicate that the catheter is not in the vein properly, which requires stopping the infusion to prevent tissue damage.

A. Administering IV opioids to reduce pain. B. After rewarming, the extremity should be lowered to reduce edema. C. Immersion of hands and feet in warm water. D. Elevating affected limbs. E. Do not give tetanus prophylaxis.

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

Explanation

Choice A rationale
Administering IV opioids can help manage the intense pain associated with frostbite, improving patient comfort during rewarming and recovery.
Choice B rationale
After rewarming, the extremity should be elevated, not lowered, to reduce edema by encouraging fluid return to the central circulation.
Choice C rationale
Immersing hands and feet in warm water is a crucial step in the rewarming process, which helps restore blood flow and prevent further tissue damage.
Choice D rationale
Elevating affected limbs after rewarming helps reduce edema and prevents further swelling and complications.
Choice E rationale
Tetanus prophylaxis is recommended in frostbite cases as frostbite injuries can break the skin, increasing the risk of tetanus infection. Hence, avoiding tetanus prophylaxis is incorrect.

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Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is monitoring a client who is receiving vincristine through a peripheral line. The nurse should monitor the client for which of the following complications indicating the need to stop the infusion? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

Treatment for frostbite includes which actions? (Select all that apply.)

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

Explanation

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