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Question 1 of 5

While administering a chemotherapeutic vesicant, the nurse notes that there is a lack of blood return from the IV catheter. The nurse should:

Correct Answer: A

Rationale: Lack of blood return suggests possible extravasation of a vesicant, which can cause tissue damage; stopping the infusion immediately prevents further harm.

Question 2 of 5

The nurse is preparing to walk the postpartum client for the first time since delivery. Before walking the client, the nurse should:

Correct Answer: B

Rationale: Dangling the legs before walking helps assess for orthostatic hypotension and ensures the client is stable, reducing the risk of fainting.

Question 3 of 5

A young woman is transferred to a psychiatric crisis unit with a diagnosis of a dissociative disorder. The nurse knows which of the following comments by the client is MOST indicative of this disorder?

Correct Answer: C

Rationale: Dissociative disorders involve a disruption in the normal integration of consciousness, memory, identity, or perception. The statement 'I feel like I'm watching myself from outside my body' is indicative of depersonalization, a common symptom of dissociative disorders. Option A is associated with PTSD, B suggests a physical issue, and D is characteristic of psychotic disorders.

Question 4 of 5

The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intravenous Pitocin, the nurse should monitor for:

Correct Answer: B

Rationale: Pitocin can cause uterine hyperstimulation, leading to fetal bradycardia, which requires close monitoring.

Question 5 of 5

The nurse is caring for a client with a wound with purulent, foul-smelling drainage. A wound culture is ordered. Which describes the correct collection technique?

Correct Answer: A

Rationale: Cleaning the wound with saline removes surface contaminants, ensuring an accurate culture from viable tissue.

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