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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Jugular vein distention:
Jugular vein distention is not typically associated with an increased risk of a stroke. It may be indicative of issues related to cardiac or fluid volume status.
B. Carotid bruit:
This is the correct answer. A carotid bruit, an abnormal sound caused by turbulent blood flow through the carotid artery, may indicate the presence of atherosclerosis and increased risk of stroke. It suggests a narrowing or blockage in the carotid artery, which can potentially lead to emboli and subsequent stroke.
C. Nuchal rigidity:
Nuchal rigidity, stiffness of the neck, is associated with conditions such as meningitis but is not a direct risk factor for a stroke.
D. Palpable cervical lymph node:
Palpable cervical lymph nodes may be indicative of infection or inflammation in the head and neck region but are not directly associated with an increased risk of a stroke.
Correct Answer is D
Explanation
A. Reduced pain in eczematous areas:
While hydration of the skin may contribute to reduced pain in some cases, the primary goal of urea cream is to moisturize and hydrate the skin rather than directly address pain.
B. Healing with a return to normal skin appearance:
Urea cream can contribute to the healing process by hydrating the skin and promoting the removal of dry, scaly skin. However, complete healing and a return to normal skin appearance may also depend on the underlying cause of eczema and other factors.
C. Decreased weeping of ulcerations in affected areas:
Urea cream can help reduce excessive dryness and weeping in eczematous areas by promoting hydration and moisture balance. However, it may not directly address ulcerations, and other interventions may be needed for open wounds.
D. Hydration of affected dry skin areas:
This is the correct answer. Urea is a natural moisturizing factor that helps retain water in the skin. Applying urea cream to affected dry skin areas is expected to hydrate the skin, reduce dryness, and improve the overall moisture balance.
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