The nurse is preparing to administer an intravenous vesicant medication to a client. Which of the following findings should the nurse identify as a complication of extravasation?

Air embolism

Tissue necrosis

Edema

Thrombus formation

Answer and Explanation

The Correct Answer is B

Choice A reason: Air embolism occurs when air enters the bloodstream, not from vesicant extravasation. Vesicants, like chemotherapy drugs, cause local tissue damage when leaking outside the vein, leading to necrosis, not vascular occlusion, making air embolism an incorrect complication in this context.

Choice B reason: Tissue necrosis is a primary complication of vesicant extravasation, as these medications (e.g., chemotherapy agents) are toxic to tissues outside the vein. Leakage causes severe damage, leading to cell death, ulceration, and potential tissue loss, making this the critical complication to identify and manage.

Choice C reason: Edema may occur with extravasation due to fluid leakage but is not the primary concern with vesicants. Vesicant extravasation causes severe tissue damage, leading to necrosis rather than just swelling, making edema a less specific and severe complication in this scenario.

Choice D reason: Thrombus formation is a risk with intravenous catheters but not a direct result of vesicant extravasation. Vesicants cause chemical damage to tissues, leading to necrosis, not clot formation, making thrombus an incorrect choice for vesicant extravasation’s primary effect.

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Correct Answer is C

Explanation

Choice A reason: Reducing anxiety about tracheostomy self-care aids long-term adjustment but is not the immediate priority. A new tracheostomy requires vigilant monitoring for complications like infection or skin breakdown at the stoma, which can lead to serious infections or tissue damage if not addressed promptly.

Choice B reason: Reassuring the client that the tracheostomy is temporary may provide emotional support but is not the priority. Many tracheostomies are permanent, and assuming temporariness may mislead. Immediate care focuses on preventing complications like stoma infections, making skin assessment more critical than reassurance.

Choice C reason: Frequent assessment of the skin around the tracheostomy stoma prevents complications like infection, pressure ulcers, or tissue necrosis. The stoma is prone to irritation from secretions and tube movement, which can foster bacterial growth and skin breakdown, necessitating vigilant monitoring to ensure healing and prevent serious infections.

Choice D reason: Referring to a support group aids long-term coping but is not the immediate priority. A new tracheostomy requires focus on preventing physical complications like infection or skin breakdown at the stoma, which pose immediate risks, making skin assessment more urgent than psychosocial support.

A. Ask the UAP to reassess the client B. Reassess the client to validate these vital signs C. Notify the healthcare provider of these vital signs D. Sit the client up in bed

Correct Answer is B

Explanation

Choice A reason: Asking the UAP to reassess delays accurate assessment by a qualified nurse. Pulse 122 and BP 98/72 suggest tachycardia and hypotension, requiring professional validation and intervention, making this less appropriate than direct nurse reassessment and provider notification.

Choice B reason: Reassessing the client validates vital signs (pulse 122, BP 98/72), indicating tachycardia and hypotension, possibly from hypovolemia or sepsis. Accurate nurse assessment ensures reliable data for diagnosis, preventing complications like shock, making this a critical action in this scenario.

Choice C reason: Notifying the provider is essential, as tachycardia (pulse 122) and hypotension (BP 98/72) suggest serious conditions like hypovolemia or sepsis. Prompt reporting ensures timely interventions, such as fluids or diagnostics, preventing deterioration, making this necessary alongside reassessment.

Choice D reason: Sitting the client up may improve breathing but does not address tachycardia and hypotension, which suggest hypovolemia or other issues. These vital signs require reassessment and provider notification to diagnose and treat the cause, making positioning less urgent.

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The nurse is preparing to administer an intravenous vesicant medication to a client. Which of the following findings should the nurse identify as a complication of extravasation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a new tracheostomy. What will the nurse prioritize for care?

Correct Answer is C

Explanation

The unlicensed assistive personnel (UAP) notifies the nurse of these vital signs for a client on the medical-surgical unit: temperature 97.6°F, respirations 20, pulse 122, and BP 98/72. Which actions should the nurse do next?

Correct Answer is B

Explanation

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