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31. An infection in a central venous access device is not eliminated by giving antibiotics through the catheter. Howwould bacterial glycocalyx contribute to this?1. It protects the bacteria from antibiotic and immunologic destruction.2. Glycocalyx neutralizes the antibiotic rendering it ineffective.3. It competes with the antibiotic for binding sites on the microbe.4. Glycocalyx provides nutrients for microbial growth.
(1) Glycocalyx is a viscous polysaccharide or polypeptide slime that covers microbes. It enhances adherence to surfaces,resists phagocytic engulfment by the white blood cells, and prevents antibiotics from contacting the microbe.Glycocalyx does not have the effects in options 2–4.
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32. Central venous access devices are beneficial in pediatric therapy because:1. they don’t frighten children.2. use of the arms is not restricted.3. they cannot be dislodged.4. they are difficult to see.
(2) The child can move his extremities and function in a normal fashion. This lessens stress associated with positionrestriction and promotes normal activity. Fear may not be eliminated. All lines can be dislodged. Even small catheterscan be readily seen.
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33. How can central venous access devices (CVADs) be of value in a patient receiving chemotherapy who hasstomatitis and severe diarrhea?1. The chemotherapy can be rapidly completed allowing the stomatitis and diarrhea to resolve.2. Crystalloid can be administered to prevent dehydration.3. Concentrated hyperalimentation fluid can be administered through the CVAD.4. The chemotherapy dose can be reduced.
(3) In patients unable to take oral nutrition, parenteral hyperalimentation is an option for providing nutritional support.High concentrations of dextrose, protein, minerals, vitamins, and trace elements can be provided. Dosing is not affectedwith options 1 and 4. Crystalloid can provide free water but has very little nutritional benefits. Hyperalimentation canprovide free water and considerable nutritional benefits.
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34. Some central venous access devices (CVAD) have more than one lumen. These multilumen catheters:1. have an increased risk of infiltration.2. only work a short while because the small bore clots off.3. are beneficial to patient care but are prohibitively expensive.4. allow different medications or solutions to be administered simultaneously.
(4) A multilumen catheter contains separate ports and means to administer agents. An agent infusing in one port cannotmix with an agent infusing into another port. Thus, agents that would be incompatible if given together can be given inseparate ports simultaneously.
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35. Some institutions will not infuse a fat emulsion, such as Intralipid, into central venous access devices (CVAD)because:1. lipid residue may accumulate in the CVAD and occlude the catheter.2. if the catheter clogs, there is no treatment other than removal and replacement.3. lipids are necessary only in the most extreme cases to prevent essential fatty acid (EFA) deficiency.4. fat emulsions are very caustic.
(1) Occlusion occurs with slow infusion rates and concurrent administration of some medications. Lipid occlusionsmay be treated with 70 percent ethanol or with 0.1 mmol/mL NaOH. Lipids provide essential fatty acids. It is recommendedthat approximately 4 percent of daily calories be EFAs. A deficiency can quickly develop. Daily essential fattyacids are necessary for constant prostaglandin production. Lipids are almost isotonic with blood.
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36. A patient needs a percutaneously inserted central catheter (PICC) for prolonged IV therapy. He knows it can beinserted without going to the operating room. He mentions that, “at least the doctor won’t be wearing surgicalgarb, will he?” How will the nurse answer the patient?1. “You are correct. It is a minor procedure performed on the unit and does not necessitate surgical attire.”2. “To decrease the risk of infection, the doctor inserting the PICC will wear a cap, mask, and sterile gownand gloves.”3. “It depends on the doctor’s preference.”4. “Most doctors only wear sterile gloves, not a cap, mask, or sterile gown.”
(2) Strict aseptic technique including the use of cap, mask, and sterile gown and gloves is require when placing a centralvenous line including a PICC. Options 1, 2, and 4 are incorrect statements. They increase the risk of infection.
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37. A patient is to receive a percutaneously inserted central catheter (PICC). He asks the nurse whether the insertionwill hurt. How will the nurse reply?1. “You will have general anesthesia so you won’t feel anything.”2. “It will be inserted rapidly, and any discomfort is fleeting.”3. “The insertion site will be anesthetized. Threading the catheter through the vein is not painful.”4. “You will receive sedation prior to the procedure.”
(3) Pain related to PICC insertion occurs with puncture of the skin. When inserting PICC lines, the insertion site isanesthetized so no pain is felt. The patient will not receive general anesthesia or sedation. Statement 2 is false.Unnecessary pain should be prevented.
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38. What volume of air can safely be infused into a patient with a central venous access device (CVAD)?1. It is dependent on the patient’s weight and height.2. Air entering the patient through a CVAD will follow circulation to the lungs where it will be absorbed andcause no problems.3. It is dependent on comorbidities such as asthma or chronic obstructive lung disease.4. None.
(4) Any air entering the right heart can lead to a pulmonary embolus. All air should be purged from central venouslines; none should enter the patient.
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39. A new staff nurse asks her preceptor nurse how to obtain a blood sample from a patient with a portacath device.The preceptor nurse teaches the new staff nurse:1. the sample will be withdrawn into a syringe attached to the portacath needle and then placed into avacutainer.2. portacath devices are not used to obtain blood samples because of the risk of clot formation.3. the vacutainer will be attached to the portacath needle to obtain a direct sample.4. any needle and syringe may be utilized to obtain the sample.
(1) A special portacath needle is used to access the portacath device. A syringe is attached and the sample is obtained.One of the primary reasons for insertion of a portacath device is the need for frequent or long-term blood sampling. Avacutainer will exert too much suction on the central line resulting in collapse of the line. Only special portacath needlesshould be used to access the portacath device.
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40. What is the purpose of “tunneling” (inserting the catheter 2–4 inches under the skin) when the surgeon inserts aHickman central catheter device? Tunneling:1. increases the patient’s comfort level.2. decreases the risk of infection.3. prevents the patient’s clothes from having contact with the catheter.4. makes the catheter less visible to other people.
(2) The actual access to the subclavian vein is still just under the clavicle, but by tunneling the distal portion of thecatheter several inches under the skin the risk of migratory infection is reduces compared to a catheter that enters thesubclavian vein directly and is not tunneled. The catheter is tunneled to prevent infection.
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41. The primary complication of a central venous access device (CVAD) is:1. thrombus formation in the vein.2. pain and discomfort.3. infection.4. occlusion of the catheter as the result of an intra-lumen clot.
(3) A foreign body in a blood vessel increases the risk of infection. Catheters that come outside the body have an evenhigher risk of infection. Most infections are caused by skin bacteria. Other infective organisms include yeasts and fungi.Options 1 and 4 are complications of a CVAD but are not the primary problem. Once placed, these lines do not causepain and discomfort.
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42. The nurse is doing some patient education related to a patient’s central venous access device. Which of thefollowing statements will the nurse make to the patient?1. “These type of devices are essentially risk free.”2. “These devices seldom work for more than a week or two necessitating replacement.”3. “The dressing should only the changed by your doctor.”4. “Heparin in instilled into the lumen of the catheter to decrease the risk of clotting.”
(4) A solution containing heparin is used to reduce catheter clotting and maintain patency. The concentration of heparinused depends on the patient’s age, comorbidities, and the frequency of catheter access/flushing. Although patients havefew complications, the device is not risk free. Patients may develop infection, catheter clots, vascular obstruction, pneumothorax,hemothorax, or mechanical problems (catheter breakage). Strict adherence to protocol enhances the longevityof central access devices. They routinely last weeks to months and sometimes years. The patient will be taught how toperform dressing changes at home.
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43. The chemotherapeutic DNA alkylating agents such as nitrogen mustards are effective because they:1. cross-link DNA strands with covalent bonds between alkyl groups on the drug and guanine baseson DNA.2. have few, if any, side effects.3. are used to treat multiple types of cancer.4. are cell cycle-specific agents.
(1) Alkylating agents are highly reactive chemicals that introduce alkyl radicals into biologically active molecules andthereby prevent their proper functioning, replication, and transcription. Alkylating agents have numerous side effectsincluding alopecia, nausea, vomiting, and myelosuppression. Nitrogen mustards have a broad spectrum of activityagainst chronic lymphocytic leukemia, non-Hodgkin’s lymphoma, and breast and ovarian cancer, but they are effectivechemotherapeutic agents because of DNA cross-linkage. Alkylating agents are noncell cycle-specific agents.
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44. Hormonal agents are used to treat some cancers. An example would be:1. thyroxine to treat thyroid cancer.2. ACTH to treat adrenal carcinoma.3. estrogen antagonists to treat breast cancer.4. glucagon to treat pancreatic carcinoma.
(3) Estrogen antagonists are used to treat estrogen hormone-dependent cancer, such as breast carcinoma. A well-knownestrogen antagonist used in breast cancer therapy is tamoxifen (Nolvadex). This drug, in combination with surgery andother chemotherapeutic drugs reduces breast cancer recurrence by 30 percent. Estrogen antagonists can also be administeredto prevent breast cancer in women who have a strong family history of the disease. Thyroxine is a natural thyroidhormone. It does not treat thyroid cancer. ACTH is an anterior pituitary hormone, which stimulates the adrenalglands to release glucocorticoids. It does not treat adrenal cancer. Glucagon is a pancreatic alpha cell hormone, whichstimulates glycogenolysis and gluconeogenesis. It does not treat pancreatic cancer.
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45. Chemotherapeutic agents often produce a certain degree of myelosuppression including leukopenia. Leukopeniadoes not present immediately but is delayed several days to weeks because:1. the patient’s hemoglobin and hematocrit are normal.2. red blood cells are affected first.3. folic acid levels are normal.4. the current white cell count is not affected by chemotherapy.
(4) The time required to clear circulating cells before the effect that chemotherapeutic drugs have on precursor cellmaturation in the bone marrow becomes evident. Leukopenia is an abnormally low white blood cell count. Answers 1–3pertain to red blood cells.
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46. Currently, there is no way to prevent myelosuppression. However, there are medications available to elicit amore rapid bone marrow recovery. An example is:1. Epoetin alfa (Epogen, Procrit).2. Glucagon.3. Fenofibrate (Tricor).4. Lamotrigine (Lamictal).
(1) Epoetin alfa (Epogen, Procrit) is a recombinant form of endogenous erythropoietin, a hematopoietic growth factornormally produced by the kidney that is used to induce red blood cell production in the bone marrow and reduce theneed for blood transfusion. Glucagon is a pancreatic alpha cell hormone, which cause glycogenolysis and gluconeogenesis.Fenofibrate (Tricor) is an antihyperlipidemic agent that lowers plasma triglycerides. Lamotrigine (Lamictal) is ananticonvulsant.
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47. Estrogen antagonists are used to treat estrogen hormone-dependent cancer, such as breast carcinoma. Androgenantagonists block testosterone stimulation of androgen-dependent cancers. An example of an androgen-dependentcancer would be:1. prostate cancer.2. thyroid cancer.3. renal carcinoma.4. neuroblastoma.
(1) Prostate tissue is stimulated by androgens and suppressed by estrogens. Androgen antagonists will block testosteronestimulation of prostate carcinoma cells. The types of cancer in options 2–4 are not androgen dependent.
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48. Serotonin release stimulates vomiting following chemotherapy. Therefore, serotonin antagonists are effective inpreventing and treating nausea and vomiting related to chemotherapy. An example of an effective serotoninantagonist antiemetic is:1. ondansetron (Zofran).2. fluoxetine (Prozac).3. paroxetine (Paxil).4. sertraline (Zoloft).
(1) Chemotherapy often induces vomiting centrally by stimulating the chemoreceptor trigger zone (CTZ) and peripherallyby stimulating visceral afferent nerves in the GI tract. Ondansetron (Zofran) is a serotonin antagonist that bocks theeffects of serotonin and prevents and treats nausea and vomiting. It is especially useful in single-day highly emetogeniccancer chemotherapy (for example, cisplatin). The agents in options 2–4 are selective serotonin reuptake inhibitors.They increase the available levels of serotonin.
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49. Methotrexate, the most widely used antimetabolite in cancer chemotherapy does not penetrate the centralnervous system (CNS). To treat CNS disease this drug must be administered:1. intravenously.2. subcutaneously.3. intrathecally.4. by inhalation.
(3) With intrathecal administration chemotherapy is injected through the theca of the spinal cord and into the subarachnoidspace entering into the cerebrospinal fluid surrounding the brain and spinal cord. The methods in options 1, 2, and4 are ineffective because the medication cannot enter the CNS.
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50. Methotrexate is a folate antagonist. It inhibits enzymes required for DNA base synthesis. To prevent harm tonormal cells, a fully activated form of folic acid known as leucovorin (folinic acid; citrovorum factor) can beadministered. Administration of leucovorin is known as:1. induction therapy.2. consolidation therapy.3. pulse therapy.4. rescue therapy.
(4) Leucovorin is used to save or “rescue” normal cells from the damaging effects of chemotherapy allowing them tosurvive while the cancer cells die. Therapy to rapidly reduce the number of cancerous cells is the induction phase.Consolidation therapy seeks to complete or extend the initial remission and often uses a different combination of drugsthan that used for induction. Chemotherapy is often administered in intermittent courses called pulse therapy. Pulsetherapy allows the bone marrow to recover function before another course of chemotherapy is given.
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51. Patients undergoing chemotherapy may also be given the drug allopurinol (Zyloprim, Aloprim). Allopurinolinhibits the synthesis of uric acid. Concomitant administration of allopurinol prevents:1. myelosuppression.2. gout and hyperuricemia.3. pancytopenia.4. cancer cell growth and replication.
2) Prevent uric acid nephropathy, uric acid lithiasis, and gout during cancer therapy since chemotherapy causes therapid destruction of cancer cells leading to excessive purine catabolism and uric acid formation. Allopurinol can inducemyelosuppression and pancytopenia. Allopurinol does not have this function.
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52. Superficial bladder cancer can be treated by direct instillation of the antineoplastic antibiotic agent mitomycin(Mutamycin). This process is termed:1. intraventricular administration.2. intravesical administration.3. intravascular administration.4. intrathecal administration.
(2) Medications administered intravesically are instilled into the bladder. Intraventricular administration involves theventricles of the brain. Intravascular administration involves blood vessels. Intrathecal administration involves the fluidsurrounding the brain and spinal cord.
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53. The most common dose-limiting toxicity of chemotherapy is:1. nausea and vomiting.2. bloody stools.3. myelosuppression.4. inability to ingest food orally due to stomatitis and mucositis.
(3) The overall goal of cancer chemotherapy is to give a dose large enough to be lethal to the cancer cells, but smallenough to be tolerable for normal cells. Unfortunately, some normal cells are affected including the bone marrow.Myelosuppression limits the body’s ability to prevent and fight infection, produce platelets for clotting, and manufacturered blood cells for oxygen portage. Even though the effects in options 1, 2, and 4 are uncomfortable and distressingto the patient, they do not have the potential for lethal outcomes that myelosuppression has.
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54. Chemotherapy induces vomiting by:1. stimulating neuroreceptors in the medulla.2. inhibiting the release of catecholamines.3. autonomic instability.4. irritating the gastric mucosa.
(1) Vomiting (emesis) is initiated by a nucleus of cells located in the medulla called the vomiting center. This centercoordinates a complex series of events involving pharyngeal, gastrointestinal, and abdominal wall contractions that leadto expulsion of gastric contents. Catecholamine inhibition does not induce vomiting. Chemotherapy does not inducevomiting from autonomic instability. Chemotherapy, especially oral agents, may have an irritating effect on the gastricmucosa, which could result in afferent messages to the solitary tract nucleus, but these pathways do not project to thevomiting center.
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55. Myeloablation using chemotherapeutic agents is useful in cancer treatment because:1. it destroys the myelocytes (muscle cells).2. it reduces the size of the cancer tumor.3. after surgery, it reduces the amount of chemotherapy needed.4. it destroys the bone marrow prior to transplant.
(4) Myelo comes from the Greek word myelos, which means marrow. Ablation comes from the Latin word ablatio,which means removal. Thus, myeloablative chemotherapeurtic agents destroy the bone marrow. This proceduredestroys normal bone marrow as well as the cancerous marrow. The patient’s bone marrow will be replaced with a bonemarrow transplant. Myelocytes are not muscle cells Tumors are solid masses typically located in organs. Surgery maybe performed to reduce tumor burden and require less chemotherapy afterward.
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56. Anticipatory nausea and vomiting associated with chemotherapy occurs:1. within the first 24 hours after chemotherapy.2. 1–5 days after chemotherapy.3. before chemotherapy administration.4. while chemotherapy is being administered.
(3) Nausea and vomiting (N&V) are common side effects of chemotherapy. Some patients are able to trigger theseevents prior to actually receiving chemotherapy by anticipating, or expecting, to have these effects. N&V occurringpost-chemotherapeutic administration is not an anticipatory event but rather an effect of the drug. N&V occurring duringthe administration of chemotherapy is an effect of the drug.
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57. Medications bound to protein have the following effect:1. enhancement of drug availability.2. rapid distribution of the drug to receptor sites.3. the more drug bound to protein, the less available for desired effect.4. increased metabolism of the drug by the liver.
(3) Only an unbound drug can be distributed to active receptor sites. Therefore, the more of a drug that is bound to protein,the less it is available for the desired drug effect. Less drug is available if bound to protein. Distribution to receptorsites is irrelevant since the drug bound to protein cannot bind with a receptor site. Metabolism would not be increased.The liver will first have to remove the drug from the protein molecule before metabolism can occur. The protein is thenfree to return to circulation and be used again.
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58. The nurse has physician orders to not administer a calcium supplement to a patient if the patient’s serumcalcium is within the normal range. As the nurse, you must determine whether to give or not give themedication. The following formula can be utilized to calculate the corrected total serum calcium whenhypoalbuminemia is present and an ionized calcium value cannot be obtained:corrected total serum calcium = measured serum calcium + 0.8 (4.0 – measured serum albumin)The total serum calcium is 7.7 mg/dL, and the measured serum albumin is 2.5 gm/dL. Calculate the answerand determine whether the corrected total serum calcium is normal.1. 8.9 mg/dL, normal2. 6.9 mg/dL, normal3. 2.4 mg/dL, abnormal4. 13.3 mg/dL, abnormal
(1) A poor correlation between serum ionized calcium and total serum calcium exists particularly when hypoalbuminemiais present. If an ionized calcium value cannot be obtained, the corrected total calcium can be estimated by assuminga normal serum albumin of 4.0 and using the preceding formula. Normal serum calcium levels are 8–10 mg/dL. Thevalue is normal.
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59. Some drugs are excreted into bile and delivered to the intestines. Prior to elimination from the body, the drugmay be absorbed. This process is known as:1. hepatic clearance.2. total clearance.3. enterohepatic cycling.4. first-pass effect.
(3) Drugs and drug metabolites with molecular weights higher than 300 may be excreted via the bile, stored in the gallbladder,delivered to the intestines by the bile duct, and then reabsorbed into the circulation. This process reduces theelimination of drugs and prolongs their half-life and duration of action in the body. Hepatic clearance is the amount of drug eliminated by the liver. Total clearance is the sum of all types of clearance including renal, hepatic, and respiratory.First-pass effect is the amount of drug absorbed from the GI tract and then metabolized by the liver; thus, reducingthe amount of drug making it into circulation.
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60. A patient has been taking a drug (Drug A) that is highly metabolized by the cytochrome p-450 system. He hasbeen on this medication for 6 months. At this time, he is started on a second medication (Drug B) that is aninducer of the cytochrome p-450 system. You should monitor this patient for:1. increased therapeutic effects of Drug A.2. increased adverse effects of Drug B.3. decreased therapeutic effects of Drug A.4. decreased therapeutic effects of Drug B.
(3) Drug B will induce the cytochrome p-450 enzyme system of the liver; thus, increasing the metabolism of Drug A.Therefore, Drug A will be broken down faster and exert decreased therapeutic effects. Drug A will be metabolizedfaster, thus reducing, not increasing its therapeutic effect. Inducing the cytochrome p-450 system will not increase theadverse effects of Drug B. Drug B induces the cytochrome p-450 system but is not metabolized faster. Thus, the therapeuticeffects of Drug B will not be decreased.
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