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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

Initiating a hearing and vision screening program for first graders is an example of secondary prevention. Secondary prevention aims to identify and treat an illness or disease at an early stage, which is exactly what a screening program does.

Choice B rationale
Observing a person with type I diabetes mellitus self-administer a dose of insulin is not an example of secondary prevention. This is more related to disease management, which falls under tertiary prevention.

Choice C rationale
Preparing a presentation on how to prevent the spread of lice is an example of primary prevention, which aims to prevent disease or injury before it ever occurs.

Choice D rationale
Collaborating with a science teacher to prepare a health lesson could be seen as primary prevention if the lesson is about preventing disease, or tertiary prevention if it’s about managing existing conditions.

A. Inquire if the patient is experiencing any pain during urination. B. Encourage the patient to increase their intake of high-protein foods. C. Review the patient’s current food and medication allergies. D. Determine if the patient has recently experienced a fall. E. Provide instructions on how to take the patient’s temperature.

Correct Answer is ["A","C","D","E"]

Explanation

Choice A rationale
A sudden change in behavior, especially confusion and agitation, in an elderly patient could be a sign of a urinary tract infection (UTI). Pain during urination is a common symptom of UTIs.
Therefore, it is crucial to inquire if the patient is experiencing any pain during urination.
Choice B rationale

While a high-protein diet can be beneficial for some patients, there is no direct link between increased protein intake and the alleviation of confusion or agitation in elderly patients.
Therefore, this option is not a necessary immediate action for the nurse to take.
Choice C rationale
Reviewing the patient’s current food and medication allergies is important. Certain medications or foods might cause adverse reactions, including confusion and agitation. Therefore, it is crucial to review the patient’s allergies to rule out any potential allergens as the cause of the sudden change in behavior.
Choice D rationale
A recent fall could potentially lead to a head injury, which might cause confusion and agitation. Therefore, it is important to determine if the patient has recently experienced a fall.
Choice E rationale
Providing instructions on how to take the patient’s temperature is important. Fever could be a sign of an infection or other medical condition that might cause confusion and agitation.
Therefore, knowing how to accurately measure the patient’s temperature can help monitor the patient’s condition.

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Which intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an intravenous (IV) site in the client’s arm?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What action should the school nurse take to provide secondary prevention for school-aged children?

Correct Answer is A

Explanation

Correct Answer is ["A","C","D","E"]

Explanation

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