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. Drink at least 8 cups (1920 mL) of water per day:
This is the correct answer. Adequate hydration is important in the management of gout because it helps to flush out uric acid and prevent the formation of urate crystals. Increasing fluid intake, especially water, is a key component of gout management.

B. Eat high protein foods to achieve ideal body weight:
While maintaining a healthy weight is important in managing gout, the emphasis should be on a balanced diet that includes adequate hydration and avoidance of foods high in purines, which can contribute to increased uric acid levels.

C. Encourage active range of motion to limit stiffness:
Active range of motion exercises can be beneficial for joint health, but the primary emphasis in gout management is on dietary and pharmacological interventions.

D. Use an electric heating pad when pain is at its worse:
Applying heat may provide some relief, but it is not the primary intervention for gout. Cold compresses or ice may be more appropriate for acute gout attacks.

A. Blood pH level. B. Platelet count. C. Hematocrit D. White blood cell (WBC) count.

Correct Answer is D

Explanation

A. Blood pH level:
The blood pH level is important for assessing the acid-base balance in the body. However, in the context of purulent drainage from a wound, it is not the primary laboratory value to review for signs of infection.

B. Platelet count:
Platelet count is important for assessing blood clotting ability. While it is a valuable parameter in overall care, it may not be directly related to the observation of purulent drainage from a wound, which typically suggests infection rather than a clotting issue.

C. Hematocrit:
Hematocrit measures the proportion of blood that is cellular. Like platelet count, it is important for assessing overall blood composition and oxygen-carrying capacity. However, it may not be the first parameter to review when evaluating signs of infection.

D. White blood cell (WBC) count:
The WBC count is a crucial parameter when assessing for infection. An elevated WBC count is a common response to infection as the body mobilizes its immune defenses. Reviewing the WBC count is particularly relevant when purulent drainage is observed, as it may indicate an inflammatory response to infection.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?

Correct Answer is D

Explanation

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