Nursing Elites

1. What intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an IV site in the client's arm?

• A. Assess IV site frequently for signs of extravasation
• B. Monitor capillary refill distal to the infusion site
• C. Apply a topical anesthetic at the infusion site for burning
• D. Explain that temporary burning at the IV site may occur

Correct answer: A

Rationale: The correct intervention the nurse should implement during the administration of a vesicant chemotherapeutic agent via an IV site in the client's arm is to assess the IV site frequently for signs of extravasation. Vesicants are agents that can cause tissue damage if they leak into the surrounding tissues. Monitoring for signs of extravasation such as swelling, pain, or redness is crucial to prevent tissue damage and ensure prompt intervention if extravasation occurs. Choices B, C, and D are incorrect because monitoring capillary refill, applying a topical anesthetic for burning, and explaining temporary burning do not directly address the risk of extravasation associated with vesicant chemotherapeutic agents.

2. A client is admitted with the diagnosis of Wernicke’s syndrome. What assessment finding should the nurse use in planning the client’s care?

• A. Right lower abdominal pain
• B. Confusion
• C. Depression
• D. Peripheral neuropathy

Correct answer: B

Rationale: Confusion is a key symptom of Wernicke’s syndrome, which is due to thiamine deficiency. Wernicke’s syndrome is characterized by a triad of symptoms known as the classic triad, which includes confusion, ataxia, and ophthalmoplegia. Right lower abdominal pain, depression, and peripheral neuropathy are not typically associated with Wernicke’s syndrome, making them incorrect choices for this question.

3. A client who will be going to surgery states no known allergies to any medications. What is the most important nursing action for the nurse to implement next?

• A. Assess client’s knowledge of an allergic response
• B. Record 'no known drug allergies' on the preoperative checklist
• C. Flag 'no known drug allergies' on the front of the chart
• D. Assess client’s allergies to non-drug substances

Correct answer: B

Rationale: The most important action to take in this situation is to record 'no known drug allergies' on the preoperative checklist. This ensures that all healthcare staff involved in the surgery are aware of the client's stated lack of drug allergies, helping to prevent any potential adverse reactions. Assessing the client's knowledge of an allergic response (Choice A) may be valuable but is not the most crucial action at this point. Flagging 'no known drug allergies' on the front of the chart (Choice C) is less practical and visible compared to documenting it on the preoperative checklist. Assessing the client’s allergies to non-drug substances (Choice D) is not the priority in this scenario where the focus is on medications due to the upcoming surgery.

4. A client morning assessment includes bounding peripheral pulses, weight gain of 2 pounds, pitting ankle edema, and moist crackles bilaterally. Which intervention is most important for the nurse to include in this client’s plan of care?

• A. Restrict daily fluid intake to 1500 ml
• B. Weight the client every morning
• C. Maintain accurate intake and output
• D. Administer prescribed diuretic

Correct answer: D

Rationale: Administering a prescribed diuretic is the most important intervention in this scenario as the client is presenting signs of fluid overload and heart failure. Diuretics help reduce fluid retention in the body, alleviating symptoms like edema and crackles. Restricting fluid intake may be necessary in some cases, but in this acute situation, addressing the immediate fluid overload with a diuretic takes precedence. Weighing the client daily and maintaining accurate intake and output are important aspects of monitoring, but they do not directly address the urgent need to manage fluid overload.

5. A client with a severe prostatic infection that caused a blocked urethra is 3 days post-surgical urinary diversion. The healthcare provider directs the nurse to remove the suprapubic catheter to allow the client to void normally. Which intervention should the nurse implement first?

• A. Cleanse the site around the catheter
• B. Use a 20 ml syringe to deflate balloon
• C. Clamp catheter until the client voids naturally
• D. Empty urine from the urinary drainage bag

Correct answer: B

Rationale: The correct answer is to use a 20 ml syringe to deflate the balloon first when removing a suprapubic catheter. This step is essential to ensure the safe removal of the catheter without causing any harm or discomfort to the client. Deflating the balloon allows for the catheter to be easily removed. Option A, cleansing the site around the catheter, is not the initial step in this process and can be done after catheter removal. Option C, clamping the catheter until the client voids naturally, is incorrect as it can lead to complications like urinary retention. Option D, emptying urine from the urinary drainage bag, is not the first step in removing the suprapubic catheter and does not address the need to deflate the balloon for safe removal.

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