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.

Nursing Test Bank

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

Explanation

Choice A rationale
Sudden onset of confusion in an older adult could be a sign of a urinary tract infection (UTI). UTIs can cause delirium and behavioral changes in older adults. Therefore, asking if the client is experiencing any pain with urination could help identify a potential UTI.
Choice B rationale
While high protein foods are generally beneficial for health, there is no direct link between increased intake of high protein foods and sudden onset of confusion. Therefore, this option is not the most appropriate action in this situation.
Choice C rationale
Reviewing the client’s current food and medication allergies is always important in healthcare settings. However, it may not directly address the sudden onset of confusion unless the client has had a recent change in diet or medication that could have triggered an allergic reaction leading to confusion.
Choice D rationale
A recent fall could potentially cause a sudden change in mental status due to a head injury or other trauma. Therefore, determining if the client has recently experienced a fall is an appropriate action.
Choice E rationale
Fever can cause confusion, especially in older adults. Therefore, providing instruction on taking the client’s temperature can help the caregiver monitor for signs of infection that could be contributing to the client’s confusion.

A. Compare muscle strength bilaterally. B. Observe color and amount of urine. C. Determine apical pulse rate and rhythm. D. Assess strength of deep tendon reflexes.

Correct Answer is C

Explanation

Choice A rationale
Comparing muscle strength bilaterally is important in assessing overall physical health and detecting any potential neuromuscular disorders. However, in the context of a client with a history of heart failure and elevated potassium levels, this would not be the most critical intervention. High potassium levels can lead to hyperkalemia, which can cause serious heart rhythm disturbances.
Choice B rationale
Observing the color and amount of urine can provide valuable information about the client’s hydration status and kidney function. In the case of heart failure, monitoring urine output can help assess the effectiveness of diuretic therapy and the progression of the disease. However, it is not the most immediate concern given the client’s high potassium levels.
Choice C rationale

Determining the apical pulse rate and rhythm is the most important intervention in this scenario. A serum potassium level of 6.2 mEq/L is higher than the normal range (3.5-5.0 mEq/L) and can cause life-threatening heart rhythm abnormalities. Therefore, the nurse should prioritize assessing the client’s heart rhythm to detect any abnormalities caused by this electrolyte imbalance.
Choice D rationale
Assessing the strength of deep tendon reflexes can help identify changes in neuromuscular function and is often used in neurological assessments. However, it is not the most critical intervention in the context of elevated potassium levels and heart failure.

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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

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

Explanation

Correct Answer is C

Explanation

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