you are the nurse caring for a patient who is to receive iv daunorubicin a chemotherapeutic agent you start the infusion and check the insertion site

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

1. You are the nurse caring for a patient who is to receive IV daunorubicin, a chemotherapeutic agent. You start the infusion and check the insertion site as per protocol. During your most recent check, you note that the IV has infiltrated so you stop the infusion. What is your main concern with this infiltration?

A. Extravasation of the medication
B. Discomfort to the patient
C. Blanching at the site
D. Hypersensitivity reaction to the medication

Correct answer: A

Rationale:

2. You are performing an admission assessment on an older adult patient newly admitted for end-stage liver disease. What principle should guide your assessment of the patient's skin turgor?

A. Overhydration is common among healthy older adults.
B. Dehydration causes the skin to appear spongy.
C. Inelastic skin turgor is a normal part of aging.
D. Skin turgor cannot be assessed in patients over 70.

Correct answer: C

Rationale: Inelastic skin is a normal change of aging. However, this does not mean that skin turgor cannot be assessed in older patients. Dehydration, not overhydration, causes inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous and spongy. Choice A is incorrect because overhydration is not common among healthy older adults. Choice B is incorrect because dehydration leads to inelastic skin, not sponginess. Choice D is incorrect as skin turgor assessment can be done in patients of any age, including those over 70.

3. A nurse preparing to start an IV on a newly admitted patient teaches the patient about the procedure and begins to prepare the site. The nurse should always start by:

A. Leaving one hand ungloved to assess the site
B. Preparing the skin with an iodine solution
C. Asking the patient if they are allergic to latex or iodine
D. Removing excessive hair at the selected site

Correct answer: C

Rationale: Before preparing the skin, the nurse should ask the patient if they are allergic to latex or iodine, which are commonly used in IV therapy setup. This is crucial to prevent potential allergic reactions at the IV site or even life-threatening anaphylaxis. Leaving one hand ungloved (choice A) is not a recommended practice as both hands should be gloved for infection control. While preparing the skin with an iodine solution (choice B) is a step in the process, ensuring the patient's safety by checking for allergies comes first. Removing excessive hair at the selected site (choice D) is not necessary and can lead to skin irritation.

4. The term used to describe a blood sodium level of more than 145 mEq/L is:

A. hyponatremia.
B. hyperkalemia.
C. hypernatremia.
D. hypercalcemia.

Correct answer: C

Rationale: The correct answer is C: hypernatremia. Hypernatremia refers to an elevated level of sodium in the blood, specifically when it is more than 145 mEq/L. Choice A, hyponatremia, is incorrect as it refers to low sodium levels. Choice B, hyperkalemia, is incorrect as it refers to high potassium levels, not sodium. Choice D, hypercalcemia, is also incorrect as it relates to elevated calcium levels, not sodium.