The nurse is administering an intravenous vesicant chemotherapeutic agent to a client. Which assessment would require the nurse's immediate action?

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Question 1 of 5

The nurse is administering an intravenous vesicant chemotherapeutic agent to a client. Which assessment would require the nurse's immediate action?

Correct Answer: C

Rationale: Pain at the site suggests extravasation, risking tissue damage from vesicants.

Question 2 of 5

A 4 year-old child is admitted with burns on his legs and lower abdomen. When assessing the child's hydration status, which of the following indicates a less than adequate fluid replacement?

Correct Answer: B

Rationale: Rising hematocrit (hemoconcentration) and oliguria indicate inadequate fluid resuscitation.

Question 3 of 5

The nurse has been teaching an apprehensive primipara who has had initial difficulty in nursing the newborn. What observation at the time of discharge suggests that initial breast feeding is effective?

Correct Answer: A

Rationale: Calm maternal behavior and interaction suggest effective latch and feeding confidence.

Question 4 of 5

The nurse discovers that the parents of a 2 year-old child continue to use an apnea monitor each night. The parents state: 'We are concerned about the possible occurrence of sudden infant death syndrome (SIDS).' In order to take appropriate action, the nurse must understand that

Correct Answer: D

Rationale: SIDS risk peaks at 2-4 months and drops significantly after 6 months; at 2 years, monitoring is typically unnecessary.

Question 5 of 5

The nurse is assessing a child with suspected lead poisoning. Which of the following assessments is the nurse most likely to find?

Correct Answer: D

Rationale: Lead poisoning often causes neurobehavioral issues like sleep disturbances in children.

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