Which intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an intravenous (IV) site in the client’s arm?
Monitor capillary refill distal to the infusion site.
Apply a topical anesthetic at the infusion site for burning.
Assess IV site frequently for signs of extravasation.
Explain that temporary burning at the IV site may occur.
The Correct Answer is C
Choice A rationale
Monitoring capillary refill distal to the infusion site is a general nursing intervention during IV therapy. However, it is not specific to the administration of a vesicant chemotherapeutic agent.
Choice B rationale
Applying a topical anesthetic at the infusion site for burning is not a standard intervention during the administration of a vesicant chemotherapeutic agent. The burning sensation is not due to the IV site but due to the vesicant agent itself.
Choice C rationale
Assessing the IV site frequently for signs of extravasation is the most appropriate intervention during the administration of a vesicant chemotherapeutic agent. Extravasation, the leakage of the vesicant into the surrounding tissue, can cause severe local tissue damage. Early detection and intervention are crucial to minimize harm.
Choice D rationale
While it is important to explain potential side effects to the client, explaining that temporary burning at the IV site may occur is not the most crucial intervention. The priority is to monitor for and prevent extravasation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
Choice A rationale
Chills and fever are not typically associated with preeclampsia. They are more commonly seen in infections.
Choice B rationale
Lack of appetite is a non-specific symptom and can be associated with many conditions, but it is not a key indicator of preeclampsia.
Choice C rationale
Swollen hands can be a symptom of preeclampsia. This condition can cause sudden weight gain and swelling (edema), particularly in your face and hands.
Choice D rationale
Headaches are a common symptom of preeclampsia. They are often severe and may be accompanied by changes in vision.
Choice E rationale
Blurred vision is a symptom of preeclampsia. Other vision changes, such as sensitivity to light or temporary loss of vision, can also occur.
Choice F rationale
Frequent urination is not typically associated with preeclampsia. It is a common symptom in early and late pregnancy due to the growing uterus pressing on the bladder.
Correct Answer is C,A,B,D
Explanation
Choice C rationale
The first step in managing a patient with abdominal pain and distention is to complete a focused assessment. This will help the nurse determine the severity of the patient’s condition and guide subsequent interventions.
Choice A rationale
Elevating the head of the bed can help reduce the risk of aspiration, especially in a patient who has recently vomited. This is particularly important in this case as the patient’s vomit is dark brown, indicating possible upper gastrointestinal bleeding.
Choice B rationale
Sending the emesis sample to the lab is important for determining the cause of the patient’s symptoms. The lab can analyze the sample for the presence of blood or other abnormalities.
Choice D rationale
Offering PRN pain medication is important for patient comfort. However, it should be done after the assessment and initial interventions have been completed. The medication may mask symptoms that could provide important diagnostic information.
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