Which action should the nurse implement to reduce the risk of vesicant extravasation in the client who is receiving intravenous chemotherapy?

Instruct the client to drink plenty of fluids during the treatment.

Keep the head of the bed elevated until the treatment is completed.

Monitor the client's intravenous site hourly during the treatment.

Administer an antiemetic before starting the chemotherapy.

Answer and Explanation

The Correct Answer is C

A. Instruct the client to drink plenty of fluids during the treatment.
This option focuses on hydration, which is generally important during chemotherapy to flush out toxins and maintain overall health. However, it does not specifically address the risk of vesicant extravasation.

B. Keep the head of the bed elevated until the treatment is completed.
Keeping the head of the bed elevated is a measure that may be taken for certain conditions or treatments, but it is not directly related to preventing vesicant extravasation.

C. Monitor the client's intravenous site hourly during the treatment.
This is the correct choice. Monitoring the intravenous site for signs of extravasation, such as swelling, redness, or pain, is crucial when administering vesicant chemotherapy drugs. Early detection allows for prompt intervention to minimize potential tissue damage.

D. Administer an antiemetic before starting the chemotherapy.
Administering an antiemetic (a medication to prevent or alleviate nausea and vomiting) is important for managing side effects of chemotherapy, but it does not specifically address the prevention of vesicant extravasation.

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Correct Answer is A

Explanation

A. Prepare the client to return to the operating room:
This is the correct and immediate priority. Evisceration, where internal organs protrude through the surgical incision, is a surgical emergency. Returning the client to the operating room is necessary to assess the extent of the complication, address the wound dehiscence, and protect the exposed organs. This intervention aims to prevent further complications and provide necessary surgical interventions.

B. Obtain a sample of the drainage to send to the lab:
While obtaining samples for laboratory analysis can be important for infection control, in the context of a client with evisceration, the primary concern is the surgical emergency. The priority is to address the wound complication by returning to the operating room rather than focusing on laboratory analysis at this immediate moment.

C. Bring additional sterile dressing supplies to the room:
While bringing additional supplies may be necessary, the priority in this situation is to prepare for the client's return to the operating room. Once the client is in a controlled surgical environment, additional dressing changes and wound care can be performed as needed.

D. Auscultate the abdomen for bowel sound activity:
While monitoring bowel sounds is a routine nursing assessment, in the context of evisceration, the immediate concern is the exposure of internal organs and the risk of infection. Preparing for the operating room takes precedence over routine assessments.

A. Evaluate upper and lower extremities for perfusion, pulse volume, and pitting edema. B. Listen for extra heart sounds, murmurs, and rhythm with the bell of the stethoscope. C. Obtain a 12-lead electrocardiogram and begin continuous cardiac monitoring. D. Verify troponin level assessments are scheduled every 3-6 hours for a series of three

Correct Answer is C

Explanation

A. Evaluate upper and lower extremities for perfusion, pulse volume, and pitting edema:
This option focuses on assessing perfusion and circulation in the extremities. While it's important in certain situations, in the context of a client who recently underwent cardiac stent placement and is now experiencing chest pressure and shortness of breath, the priority is to assess the cardiac status more directly.

B. Listen for extra heart sounds, murmurs, and rhythm with the bell of the stethoscope:
This option involves auscultating the heart for abnormal sounds or rhythms. While it's a valuable assessment in general, in this particular scenario, obtaining an electrocardiogram (ECG) and initiating continuous cardiac monitoring would provide a more comprehensive and immediate evaluation of the cardiac status.

C. Obtain a 12-lead electrocardiogram and begin continuous cardiac monitoring:
This is the correct choice. Obtaining a 12-lead ECG and initiating continuous cardiac monitoring is crucial in assessing the client's cardiac function. It allows for the detection of any acute changes in the heart's electrical activity or rhythm, which is essential for timely intervention and management.

D. Verify troponin level assessments are scheduled every 3-6 hours for a series of three:
Monitoring troponin levels is important in assessing cardiac damage, but in this acute situation, obtaining an immediate ECG and initiating continuous cardiac monitoring take precedence for a more real-time evaluation of the client's cardiac status. Troponin levels may be monitored subsequently based on the initial findings.

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Which action should the nurse implement to reduce the risk of vesicant extravasation in the client who is receiving intravenous chemotherapy?

Nursing Test Bank

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