The next 3 questions relate to this case study:
In the event of a reaction or side effect during Ms. Anderson’s chemotherapy session, select the immediate nursing interventions you would take. Select all that apply.
Notify the oncologist or healthcare provider immediately.
Slow the chemotherapy infusion.
Stop the chemotherapy infusion.
Assess Ms. Anderson’s vital signs and symptoms.
Infuse normal saline at 100 ml/hr.
Correct Answer : A,C,D,E
Choice A reason:
Notifying the oncologist or healthcare provider immediately is crucial in the event of a reaction or side effect during chemotherapy. Prompt communication with the healthcare provider ensures that the patient receives appropriate and timely medical intervention. The oncologist can provide specific instructions on managing the reaction, including any necessary medications or adjustments to the chemotherapy regimen. Immediate notification helps in preventing the escalation of the reaction and ensures patient safety.
Choice B reason:
Slowing the chemotherapy infusion is not typically recommended as an immediate intervention for a severe reaction. While adjusting the infusion rate can be considered for mild reactions, it is not sufficient for managing more serious side effects or hypersensitivity reactions. In cases of significant reactions, stopping the infusion and taking other emergency measures are more appropriate. Slowing the infusion might delay the necessary interventions and could potentially worsen the patient’s condition.
Choice C reason:
Stopping the chemotherapy infusion is a critical step in managing a reaction. Halting the infusion immediately prevents further exposure to the causative agent, which can help in stabilizing the patient’s condition. This action is essential to prevent the reaction from worsening and allows time for the healthcare team to assess the situation and implement appropriate interventions. Stopping the infusion is a standard protocol in managing infusion-related reactions.
Choice D reason:
Assessing Ms. Anderson’s vital signs and symptoms is essential to determine the severity of the reaction and guide further interventions. Monitoring vital signs such as heart rate, blood pressure, respiratory rate, and oxygen saturation provides crucial information about the patient’s physiological status. This assessment helps in identifying any life-threatening changes and ensures that appropriate measures are taken to stabilize the patient. Continuous monitoring is vital for detecting any deterioration in the patient’s condition.
Choice E reason:
Infusing normal saline at 100 ml/hr is an important intervention to maintain intravenous access and provide fluid support. Normal saline helps in stabilizing the patient’s blood pressure and improving circulation, which can be compromised during a severe reaction. It also ensures that the IV line remains patent for the administration of emergency medications if needed. Fluid support is a key component of managing infusion-related reactions and preventing complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Apply wrist restraints to secure IV lines
Applying wrist restraints to secure IV lines should not be the first action. Restraints are generally considered a last resort due to their potential to cause harm and distress. They should only be used when absolutely necessary and after other interventions have failed. In this scenario, the patient’s agitation and confusion could be due to hypoxia, and addressing the underlying cause is more important than immediately resorting to restraints.
Choice B: Administer the prescribed opioid
Administering the prescribed opioid is not the first action to take. While pain management is crucial, opioids can sometimes exacerbate confusion and agitation, especially in the immediate postoperative period. It is essential to first assess the patient’s vital signs and oxygen levels to rule out hypoxia or other complications before administering any medication.
Choice C: Take the blood pressure and pulse
Taking the blood pressure and pulse is important but not the immediate first action. While these vital signs provide critical information about the patient’s cardiovascular status, checking the oxygen saturation is more urgent in this context. Hypoxia can lead to agitation and confusion, and addressing it promptly can stabilize the patient more effectively.
Choice D: Check the oxygen (O2) saturation
Checking the oxygen (O2) saturation should be the first action. Hypoxia is a common cause of postoperative agitation and confusion. By assessing the patient’s oxygen levels, the nurse can quickly determine if supplemental oxygen is needed, which can help alleviate the patient’s symptoms and prevent further complications. Ensuring adequate oxygenation is a priority in the immediate postoperative period.
Correct Answer is C
Explanation
Choice A: Demonstrate a caring attitude to the patient and family
While demonstrating a caring attitude is an essential aspect of nursing, it is not the primary goal of pain assessment. A caring attitude helps build trust and rapport with patients and their families, which is crucial for effective communication and overall patient care. However, the main objective of pain assessment is to gather data that will inform pain management strategies.
Choice B: Ensure complete documentation in the EHR
Ensuring complete documentation in the Electronic Health Record (EHR) is important for maintaining accurate patient records and facilitating communication among healthcare providers. However, this is a secondary goal that supports the primary objective of pain assessment. The main focus of pain assessment is to collect data that will guide pain management interventions.
Choice C: Gather subjective and objective data in order to plan and implement appropriate pain management techniques
This is the correct answer. The primary goal of a nursing pain assessment is to gather both subjective data (patient’s self-reported pain levels, descriptions, and experiences) and objective data (observations, vital signs, and physical assessments). This comprehensive data collection allows nurses to develop and implement effective pain management plans tailored to the individual needs of the patient. Accurate pain assessment is crucial for identifying the type, intensity, and cause of pain, which in turn informs the selection of appropriate pain relief measures.
Choice D: Develop a therapeutic relationship with the patient
Developing a therapeutic relationship with the patient is an important aspect of nursing care, as it fosters trust and open communication. However, it is not the primary goal of pain assessment. The main objective of pain assessment is to gather data that will inform pain management strategies. A therapeutic relationship can enhance the effectiveness of pain assessment and management, but it is a means to an end rather than the end itself.
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