A nurse is caring for a client who is receiving chemotherapy and requests information about acupuncture to relieve some of the side effects. Which of the following findings should the nurse identify as a contraindication to receiving this alternative therapy?

Urticaria

Mouth sores

Headaches

Lymphedema

Answer and Explanation

The Correct Answer is D

Lymphedema is a contraindication to acupuncture because it increases the risk of infection and worsens the swelling. Acupuncture should not be performed on an oedematous limb at risk of lymphoedema.

The other options are not contraindications to acupuncture.

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Correct Answer is D

Explanation

The nurse should plan to confirm the correct position of the line by obtaining a blood sample, as this is one of the methods to verify placement and patency of a central venous catheter. The nurse should also instruct the client to perform a Valsalva maneuver (bearing down) as the catheter is inserted, place the head of the client's bed higher than 30 degrees, and cleanse the site with an antiseptic solution such as chlorhexidine.

A. Initiate venous access with a 21-gauge needle. B. Use Y tubing with 0.9% sodium chloride when administering the transfusion. C. Administer the unit of packed RBCs over 1 hr. D. Obtain the client's first set of vital signs 1 hr after initiating the transfusion.

Correct Answer is A

Explanation

Practice standards indicateblood should be infused through a 20-gauge or larger catheter to prevent hemolysis [destruction] of red blood cells. Y tubing with 0.9% sodium chloride is used to administer blood products is not necessary.A unit of packed RBCs should be administered over 2 to 4 hours, unless otherwise ordered by the provider, to reduce the risk of fluid overload and transfusion reactions . The client's vital signs should be obtained before, during (15 minutes after starting and every hour thereafter), and after the transfusion to monitor for any signs of adverse reactions.

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A nurse is caring for a client who is receiving chemotherapy and requests information about acupuncture to relieve some of the side effects. Which of the following findings should the nurse identify as a contraindication to receiving this alternative therapy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to assist with the insertion of a non-tunneled central venous catheter for a client who is malnourished. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

A nurse is preparing to administer a unit of packed RBCS to a client. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse in a provider's office is caring for a client who has total vision loss and is the handler of a service dog. Which of the following actions should the nurse take to show consideration for the client and the service animal?

A nurse is caring for a client who understands a prescribed surgical procedure, but cannot read or write. Which of the following actions should the nurse take?

A nurse is providing dietary teaching to a client who has heart failure and a new prescription for a 2-g sodium diet. Which of the following client statements should the nurse identify as an understanding of the teaching?

A nurse is reviewing the medical record of a client who is to undergo open heart surgery. Which of the following findings should the nurse report to the provider as a contraindication to receiving heparin?

A nurse is caring for a client who has anemia. Which of the following assessment findings should the nurse anticipate with the client's condition?

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A nurse is reviewing ECG rhythm strips for a group of clients. The nurse should identify that which of the following rhythms indicates bradycardia?