Nokea
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.
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A nurse is assigned to care for a client who is receiving IV fat emulsions. The nurse reviews the client's history and identifies the need to administer the fat emulsion cautiously based on which of the following?
- A. The client has a pulmonary disorder.
- B. The client is allergic to eggs.
- C. The client has acute pancreatitis
- D. The client has a vitamin deficiency.
Correct Answer: A
Rationale: When caring for a client who is to receive IV fat emulsions, the nurse should know that IV fat emulsions are to be used cautiously if the client has a pulmonary disorder, severe liver impairment, anemia, and blood coagulation disorders.
A client has been experiencing severe vomiting. The nurse notifies the primary health care provider based on the suspicion that the client may be developing hyponatremia. Which of the following would support the nurse's suspicion? Select all that apply.
- A. Increased skin turgor
- B. Hypotension
- C. bradycardia
- D. Anxiety
- E. Cold, clammy skin
Correct Answer: B,D,E
Rationale: Signs and symptoms of hyponatremia include clammy skin, decreased skin turgor, apprehension, confusion, irritability, anxiety, hypotension, postural hypotension, tachycardia, headache, tremors, convulsions, abdominal cramps, nausea, vomiting, and diarrhea.
A physician orders normal saline for a client to replace lost fluids due to poor oral intake. The order is for 1000 mL normal saline to be infused over a period of 6 hours. If the drop factor is 20 drops/mL, the nurse would set the IV flow rate at
- A. 55 drops/min
- B. 56 drops/min
- C. 57 drops/min
- D. 58 drops/min
Correct Answer: B
Rationale: 1000 mL / 6 hours = 166.7 mL/hr; 166.7 mL/hr ? 1 hr/60 min = 2.8 mL/min; 2.8 mL/min ? 20 = 55.5 or 56 drops/min.
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 assigned to care for a client who has received albumin intravenously. The nurse understands that which of the following reasons has prompted the administration of plasma protein fractions to the client?
- A. The client must have lost a lot of blood volume due to severe hemorrhage.
- B. The client must have poor wound-healing abilities with a high risk of infection.
- C. The client must be experiencing a condition in which plasma alone is lost.
- D. The client must be experiencing hypovolemic shock due to trauma.
Correct Answer: D
Rationale: Plasma protein fractions are used in clients to treat hypovolemic shock that occurs as a result of burns, trauma, surgery, and infections or in conditions where shock is not currently present but likely to occur. It is also used in the case of hypoproteinemia, as might be seen in clients with nephrotic syndrome and hepatic cirrhosis, as well as other diseases or disorders.