Nokea
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.
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A physician orders normal saline for a client to replace lost fluids due to poor oral intake. The order is for 1000 mL D5W to be infused over a period of 4 hours. If the drop factor is 5 drops/mL, the nurse would determine the IV flow rate to be
- A. 20 drops/min
- B. 21 drops/min
- C. 22 drops/min
- D. 23 drops/min
Correct Answer: B
Rationale: 1000 mL / 4 hours = 250 mL/hr; 250 mL/hr ? 1 hr/60 min = 4.17 mL/min; 4.17 mL/min ? 5 = 20.8 or 21 drops/min.
A client is receiving an IV infusion containing calcium. The nurse would monitor the client for which of the following as a possible adverse reaction? Select all that apply.
- A. Tingling
- B. Chalky taste
- C. Numbness
- D. Vein irritation
- E. Dry skin
Correct Answer: A,B,D
Rationale: When administering calcium IV, the client may experience irritation of the vein, tingling, a metallic or chalky taste, and 'heat waves.'
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.
A nurse is administering IV fluid and electrolyte therapy to a client. The nurse reviews the client's laboratory test results. Which result would the nurse immediately report to the primary health care provider?
- A. Calcium 4.7 mEq/L
- B. Magnesium 2.0 mEq/L
- C. Potassium 2.1 mEq/L
- D. Sodium 140 mEq/L
Correct Answer: C
Rationale: The nurse would report a potassium level of 2.1 mEq/L because this indicates hypokalemia. A calcium level of 4.7 mEq/L, magnesium level of 2.0 mEq/L, and sodium level of 140 mEq/L are within normal ranges.
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.