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 C

Explanation

Choice A rationale
While the color, clarity, and odor of urine can provide important information about a patient’s overall health and hydration status, it is not the most crucial information to obtain before inserting an indwelling urinary catheter.
Choice B rationale
The patient’s ability to increase fluid intake can be important in managing various health conditions, but it is not the most important information to obtain before this procedure.
Choice C rationale
Knowing if a patient has allergies to antiseptic solutions is crucial before inserting an indwelling urinary catheter. Using an antiseptic solution that a patient is allergic to can lead to serious complications.
Choice D rationale
While a previous history of urinary tract infections can inform the care and management of a patient with an indwelling urinary catheter, it is not the most important information to obtain before the procedure.

A. Reinforce the connection of the chest tube to the container with tape. B. Immediately clamp the chest tube with a plastic clamp. C. Apply an occlusive dressing over the site of the chest tube. D. Ensure that the chest tubing is neither kinked nor hanging low.

Correct Answer is B

Explanation

Choice A rationale
Reinforcing the connection of the chest tube to the container with tape is not the immediate action to be taken when a client becomes suddenly short of breath and anxious. This action might be necessary if the connection between the chest tube and the container is loose, but it does not address the immediate need of the client.
Choice B rationale
If a client with a chest tube becomes suddenly short of breath and anxious, the nurse should immediately clamp the chest tube with a plastic clamp. This is because the chest tube might have been disconnected from the water seal chamber, and clamping the tube can prevent air from entering the pleural space and causing a tension pneumothorax.
Choice C rationale

Applying an occlusive dressing over the site of the chest tube is not the immediate action to be taken when a client becomes suddenly short of breath and anxious. This action might be necessary if the chest tube is accidentally removed, but it does not address the immediate need of the client.
Choice D rationale
Ensuring that the chest tubing is neither kinked nor hanging low is an important part of the ongoing care for a client with a chest tube, but it is not the immediate action to be taken when a client becomes suddenly short of breath and anxious.

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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

Before inserting an indwelling urinary catheter, which information about the patient is most important for the nurse to obtain?

Correct Answer is C

Explanation

A client with a right hemopneumothorax has a chest tube connected to suction. While turning to the left side, the client becomes suddenly short of breath and anxious. What should the nurse do next?

Correct Answer is B

Explanation

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