A client with cancer is receiving chemotherapy with a known vesicant. The client's IV has been in place for 72 hours. The nurse determines that a new IV site cannot be obtained, and leaves the present IV in place. What is the greatest clinical risk related to this situation?

Correct Answer: A

Rationale: In the scenario presented, the correct answer is A) Impaired skin integrity. When a vesicant medication, such as chemotherapy, leaks into the surrounding tissues due to a poorly functioning or long-standing IV site, it can cause severe damage to the skin, subcutaneous tissues, and even lead to necrosis. This poses a significant risk to the patient's health and can result in long-term complications. Option B) Fluid volume excess is not directly related to the situation described. Option C) Acute pain and anxiety may occur but are not the greatest risk compared to the potential tissue damage caused by the vesicant. Option D) Peripheral neurovascular dysfunction is also not the primary concern in this context. Educationally, understanding the importance of maintaining IV sites properly in patients receiving vesicant medications is crucial for nurses caring for oncology patients. It highlights the significance of timely assessment, intervention, and advocating for the safe administration of medications to prevent serious complications and promote patient well-being.

Correct Answer: C

Rationale: In this scenario, the correct intervention for the nurse to implement is option C, which is to palpate the bladder above the symphysis pubis. This is the correct choice because the client is exhibiting symptoms of urinary retention, such as difficulty starting the stream, frequent urination, and sensation of incomplete emptying. Palpating the bladder can help the nurse assess for bladder distension, which could indicate urinary retention. Option A, collecting a urine specimen for culture analysis, is incorrect in this situation because the client's symptoms are more indicative of a mechanical issue (urinary retention) rather than an infection. Therefore, a urine culture may not provide relevant information at this point. Option B, reviewing the client's fluid intake prior to bedtime, is also not the most appropriate choice as it does not address the immediate concern of urinary retention that the client is experiencing. While managing fluid intake is important for overall urinary health, it is not the priority intervention in this case. Option D, obtaining a fingerstick blood glucose level, is unrelated to the client's current presentation of urinary retention symptoms. This option would be more relevant if the client had symptoms suggestive of diabetes or if the nurse suspected hyperglycemia as a potential cause of the urinary issues, which is not the case here. In an educational context, understanding how to assess and address urinary retention in patients is crucial for nurses, especially when caring for older adult clients who may be more prone to this issue. Palpating the bladder is a fundamental skill that helps nurses gather important data to guide further interventions or referrals for appropriate management.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Decreased frequency of episodes of VT. Lidocaine is a class Ib antiarrhythmic medication that works by stabilizing the neuronal membrane and decreasing automaticity in the ventricles. It is commonly used to treat ventricular arrhythmias like ventricular tachycardia (VT). Therefore, a therapeutic response to lidocaine would be a reduction in the frequency or cessation of VT episodes, indicating that the medication is effectively managing the arrhythmia. Option A) Stabilization of blood pressure ranges may not be directly related to the therapeutic response of lidocaine for VT. Lidocaine primarily targets cardiac arrhythmias, and its impact on blood pressure may be secondary or indirect. Option B) Cessation of chest pain is not a typical response to lidocaine infusion for VT. While chest pain may be associated with myocardial infarction, lidocaine's primary action is on cardiac arrhythmias, not pain relief. Option C) Reducing heart rate is not the primary goal of using lidocaine for VT. The focus is on restoring normal cardiac rhythm and preventing life-threatening arrhythmias, rather than specifically targeting heart rate reduction. In an educational context, understanding the mechanism of action and therapeutic indications of antiarrhythmic medications like lidocaine is crucial for nurses caring for patients with cardiovascular conditions. By grasping the specific responses expected from these medications, nurses can effectively monitor and evaluate the effectiveness of treatment interventions, ensuring optimal patient outcomes.

Correct Answer: D

Rationale: The correct answer is D) Elevate head of bed 60 to 90 degrees. This position facilitates proper tube placement by utilizing gravity to assist in guiding the nasogastric tube into the stomach. Elevating the head of the bed also helps prevent aspiration and ensures proper positioning of the tube. Option A) Soaking the nasogastric tube in warm water is unnecessary and does not contribute to proper tube placement. Option B) Inserting the tube with the client's head tilted back can increase the risk of aspiration and is not the recommended technique for nasogastric tube insertion. Option C) Applying suction while inserting the tube is not appropriate as it can cause trauma to the nasal passages and increase the risk of incorrect tube placement. Educationally, understanding the rationale behind proper nasogastric tube placement is crucial for nurses caring for pediatric patients with gastrointestinal issues. By knowing the correct technique, nurses can ensure safe and effective interventions for their patients, preventing complications and promoting optimal outcomes.

Correct Answer: D

Rationale: In this scenario, the priority intervention for the nurse after the client's rhythm converts to supraventricular tachycardia (SVT) is to give an IV dose of adenosine rapidly over 1-2 seconds (Option D). The correct answer is D because adenosine is the drug of choice for terminating SVT by interrupting the reentry pathway through the AV node. Adenosine works by slowing conduction through the AV node, which can help restore normal sinus rhythm in cases of SVT. Option A (Prepare for transcutaneous pacing) is incorrect because transcutaneous pacing is not indicated for SVT. It is used for bradycardias or unstable tachycardias that do not respond to medications. Option B (Deliver another defibrillator shock) is incorrect because defibrillation is used for shockable rhythms like ventricular fibrillation (VF) or pulseless ventricular tachycardia, not for SVT. Option C (Administer IV Epinephrine per ACLS protocol) is incorrect because epinephrine is indicated for cardiac arrest situations or severe bradycardia, not for SVT. Educationally, it is crucial for nurses to understand the appropriate pharmacological interventions for different cardiac rhythms to provide safe and effective care to pediatric patients. Adenosine administration requires proper dosing, administration technique, and close monitoring of the patient's response to ensure successful conversion of SVT. Nurses should also be familiar with ACLS protocols and algorithms to manage various cardiac emergencies confidently.