Nokea
A client is at risk for hypercalcemic syndrome. The primary health care provider prescribes additional therapy to combat this syndrome. Which of the following would the nurse expect to be prescribed? Select all that apply.
- A. Sodium chloride
- B. Potassium
- C. Furosemide
- D. Magnesium
- E. Bicarbonate
Correct Answer: A,C
Rationale: To combat hypercalcemic syndrome, the primary health care provider may prescribe IV sodium chloride and a potent diuretic such as furosemide. When used together, these two drugs markedly increase calcium renal clearance and reduce hypercalcemia.
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A nurse is caring for a client who is receiving ammonium chloride. The nurse would be alert for the development of which of the following as a possible adverse reaction?
- A. Depressed reflexes
- B. Muscle weakness
- C. Circulatory collapse
- D. Metabolic acidosis
Correct Answer: D
Rationale: The nurse should monitor the client's condition for metabolic acidosis as an adverse reaction to ammonium chloride.
A client is prescribed total parenteral nutrition due to weight loss secondary to cancer treatment. The nurse would most likely identify which nursing diagnosis as the priority?
- A. Risk for Injury
- B. Imbalanced Nutrition: Less Than Body Requirements
- C. Deficient Fluid Volume
- D. Risk for Decreased Cardiac Output
Correct Answer: B
Rationale: The need for total parenteral nutrition would support the nursing diagnosis of Imbalanced Nutrition: Less Than Body Requirements to help promote weight gain and nutritional stability.
A nurse suspects a client receiving an infusion of normal saline may have hypernatremia based on assessment of which of the following? Select all that apply.
- A. Fever
- B. Dry skin
- C. Thirst
- D. Polyuria
- E. Weight gain
Correct Answer: A,B,C,E
Rationale: Signs and symptoms of hypernatremia include fever, hot, dry skin; sticky mucous membranes; rough, dry tongue; edema; weight gain; intense thirst; excitement; restlessness; agitation; and oliguria or anuria.
A nurse is preparing to initiate IV access for a client who is prescribed IV fluid therapy. After selecting the site, which of the following would the nurse do next?
- A. Place a tourniquet above the selected site.
- B. Cleanse the site according to facility policy.
- C. Insert the needle while pulling the skin taut.
- D. Check for blood flow.
Correct Answer: A
Rationale: When a site has been selected for venipuncture, the nurse places a tourniquet above the selected vein, then cleanses the site according to facility policy.
After teaching a group of nursing students about plasma expanders, the instructor determines that the teaching was successful when the students identify which of the following as an example? Select all that apply.
- A. Normal saline
- B. Hetastarch
- C. Dextran
- D. D5W
- E. Albuminar/Buminate
Correct Answer: B,C
Rationale: The following are examples of plasma expanders: hetastarch (Hespan), low-molecular-weight dextran (Dextran 40), and high-molecular-weight dextran (Dextran 75).