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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Reassuring the adolescent that experiencing phantom limb pain can be a normal post-surgical sensation is the correct choice. Phantom limb pain is a common occurrence after amputation and can be very distressing for the patient. The nurse should validate the patient’s experience and provide reassurance. Non-pharmacological interventions such as mirror therapy, visualization, and other cognitive-behavioral strategies can also be helpful.
Choice B rationale
Guiding the patient in moving the non-affected limb to override the sensation being experienced is not the most appropriate intervention. While some therapies for phantom limb pain involve focusing on the remaining limb, this should be done under the guidance of a trained therapist.
Choice C rationale
Telling the patient that the sensations of tingling and pain are not real is not an appropriate intervention. Although the limb is no longer there, the pain that the patient is experiencing is very real. It is important to validate the patient’s experience and provide appropriate interventions.
Choice D rationale
Affirming that a prosthetic with physical therapy will gradually improve the symptoms is not the most appropriate intervention. While using a prosthetic and engaging in physical therapy can help with overall recovery and adaptation after amputation, they do not directly address phantom limb pain. The pain is a result of mixed signals from the brain and nerves, and it requires specific interventions.
Correct Answer is C
Explanation
Choice A rationale
Moon facies, characterized by a round face, is a side effect of long-term use of prednisone. However, it is not the most important symptom for the client to report to the healthcare provider in this context.
Choice B rationale
Abdominal striae, or stretch marks on the abdomen, can also be a side effect of long-term use of prednisone. While it may be a concern for some patients due to cosmetic reasons, it is not the most critical symptom to report in this case.
Choice C rationale
Gastric irritation is a common side effect of prednisone and can lead to more serious complications such as gastric ulcers if not addressed promptly. Therefore, it is the most important symptom for the client to report to the healthcare provider.
Choice D rationale
Rapid weight gain can be a side effect of prednisone use. While it is important to monitor weight while on this medication, it is not the most critical symptom to report in comparison to gastric irritation.
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