What action should the healthcare provider take to reduce the risk of vesicant extravasation in a client receiving intravenous chemotherapy?

Questions 63

ATI LPN

ATI LPN Test Bank

ATI Medical Surgical Proctored Exam 2019 Quizlet Questions

Question 1 of 5

What action should the healthcare provider take to reduce the risk of vesicant extravasation in a client receiving intravenous chemotherapy?

Correct Answer: D

Rationale: The correct answer is D: Monitor the client's intravenous site hourly during the treatment. This is crucial to reduce the risk of vesicant extravasation, which can cause tissue damage if the chemotherapy leaks into the surrounding tissues. By monitoring the IV site hourly, the healthcare provider can detect any signs of infiltration or extravasation early and take necessary actions to prevent further harm. A: Administering an antiemetic before starting chemotherapy is unrelated to preventing vesicant extravasation. B: Instructing the client to drink plenty of fluids does not directly address the risk of vesicant extravasation. C: Keeping the head of the bed elevated is not specific to preventing vesicant extravasation and may not effectively reduce the risk.

Question 2 of 5

During an admission physical assessment, the nurse is examining a newborn who is small for gestational age (SGA). Which finding should the nurse report immediately to the pediatric healthcare provider?

Correct Answer: C

Rationale: The correct answer is C: Widened, tense, bulging fontanel. This finding is concerning as it can indicate increased intracranial pressure, potentially leading to serious complications in a newborn. The fontanel should be flat or slightly depressed, not bulging. Immediate reporting is necessary for timely intervention. Incorrect choices: A: Heel stick glucose of 65 mg/dL is slightly low but not an immediate concern; can be managed with feeding. B: Head circumference of 35 cm is within the normal range for a newborn and does not require immediate action. D: High-pitched shrill cry can be a sign of distress but not as urgent as a bulging fontanel in this context.

Question 3 of 5

Which client's laboratory value requires immediate intervention by a nurse?

Correct Answer: D

Rationale: The correct answer is D because a client with an absolute neutrophil count < 500 is at high risk for serious infections due to severe neutropenia. Neutrophils are crucial for fighting infections, and a low count puts the client at immediate risk. Therefore, intervention is required to prevent life-threatening complications. Choice A: A hemoglobin of 7 grams in a client with GI bleeding receiving a blood transfusion indicates anemia, but it does not require immediate intervention unless the client is symptomatic. Choice B: A fasting glucose of 190 mg/dl in a client with pancreatitis is elevated but does not require immediate intervention unless the client is symptomatic or experiencing complications. Choice C: A bilirubin level 4 times the normal value in a jaundiced client with hepatitis is concerning but does not require immediate intervention unless there are signs of severe liver dysfunction or complications.

Question 4 of 5

In planning the turning schedule for a bedfast client, it is most important for the nurse to consider what assessment finding?

Correct Answer: B

Rationale: The correct answer is B: A Braden risk assessment scale rating score of ten. This is crucial because the Braden scale assesses the client's risk for developing pressure ulcers. A score of ten indicates a very high risk, requiring frequent repositioning to prevent pressure ulcers. Choice A is incorrect because 4+ pitting edema of both lower extremities indicates fluid overload, not directly related to turning schedule planning. Choice C is incorrect because warm, dry skin with a fever of 100‚° F suggests a possible infection, but does not affect the need for turning schedule planning. Choice D is incorrect as hypoactive bowel sounds and infrequent bowel movements are related to gastrointestinal function, not directly impacting the turning schedule.

Question 5 of 5

The healthcare provider prescribes naproxen (Naprosyn) 500 mg PO twice a day for a client with osteoarthritis. During a follow-up visit one month later, the client tells the nurse, 'The pills don't seem to be working. They are not helping the pain at all.' Which factor should influence the nurse's response?

Correct Answer: D

Rationale: Step 1: NSAID response is variable - Different individuals respond differently to NSAIDs like naproxen due to genetic and physiological differences. Step 2: Trying another NSAID may be more effective - If the current NSAID is not effective, switching to a different one with a different mechanism of action may provide better pain relief. Step 3: Individualized approach - Tailoring the treatment to the individual's response is key in managing osteoarthritis pain effectively. Summary: Choice D is correct as it acknowledges the variability in NSAID response and suggests trying another NSAID if the current one is ineffective. Choices A, B, and C are incorrect as they do not address the variable response to NSAIDs and do not provide a solution to address the lack of pain relief.

Access More Questions!

ATI LPN Basic


$89/ 30 days

ATI LPN Premium


$150/ 90 days

Similar Questions