Nokea
A client is prescribed bicarbonate. The client's medication history reveals that the client is also taking fluoroquinolones. The nurse would be alert for the development of which of the following due to an interaction of these two drugs?
- A. Respiratory alkalosis
- B. Severe abdominal pain
- C. Increased risk of crystalluria
- D. Renal impairment
Correct Answer: C
Rationale: The nurse should monitor the client's condition for an increased risk of crystalluria as a result of the interaction of fluoroquinolones and bicarbonate.
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A physician orders levofloxacin (Levaquin) for a client to treat infection. The order is for levofloxacin (Levaquin) 1000 mg/50 mL to be infused over a period of 1 hour. The IV infusion set delivers 15 drops/mL. The nurse would set the infusion rate at
- A. 12 drops/min
- B. 13 drops/min
- C. 14 drops/min
- D. 15 drops/min
Correct Answer: B
Rationale: 50 mL / 1 hour = 50 mL/hr; 50 mL/hr ? 1 hr/60 min = 0.83 mL/min; 0.83 mL/min ? 15 = 12.5 or 13 drops/min.
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.
A client who is prescribed digoxin (Lanoxin) is receiving electrolyte replacement therapy. The nurse would monitor the client for signs of digoxin toxicity if which of the following electrolytes is administered?
- A. Sodium
- B. Potassium
- C. Magnesium
- D. Phosphorous
Correct Answer: B
Rationale: The nurse should monitor a client taking digoxin (Lanoxin) for signs of digoxin toxicity if potassium is being given.
A nurse is assessing a client receiving a continuous IV infusion. The nurse suspects that the client is developing fluid overload based on assessment of which of the following? Select all that apply.
- A. Weight loss
- B. Decreased blood pressure
- C. Distended neck veins
- D. Rapid breathing
- E. Hypernatremia
Correct Answer: C,D
Rationale: Signs of fluid overload include headache, weakness, blurred vision, behavioral changes, weight gain, isolated muscle twitching, hyponatremia, rapid breathing, wheezing, coughing, rise in blood pressure, distended neck veins, elevated central venous pressure, and convulsions.
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.