Nokea
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.'
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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 may have hypocalcemia based on assessment of which of the following? Select all that apply.
- A. Hypoactive reflexes
- B. Positive Homan's sign
- C. Positive Trousseau's sign
- D. Positive Chvostek's sign
- E. Tetany
Correct Answer: C,D,E
Rationale: Signs and symptoms of hypocalcemia include hyperactive reflexes, carpopedal spasm, perioral paresthesias, positive Trousseau's and Chvostek's signs, muscle twitching, muscle cramps, tetany, laryngospasm, cardiac arrhythmias, nausea, vomiting, anxiety, confusion, emotional lability, and convulsions.
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).
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 suspects a client receiving an infusion of magnesium may be developing hypermagnesemia based on assessment of which of the following? Select all that apply.
- A. Drowsiness
- B. Diaphoresis
- C. Hypertension
- D. Absent deep tendon reflexes
- E. Impaired respiration
Correct Answer: A,B,D,E
Rationale: Signs and symptoms of hypermagnesemia include lethargy, drowsiness, impaired respiration, flushing, diaphoresis, hypotension, and weak or absent deep tendon reflexes.