Nokea
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.
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A physician orders levofloxacin (Levaquin) for a client to treat infection. The order is for levofloxacin (Levaquin) 500 mg/100 mL to be infused over a period of 1 hour. The IV infusion set has a drop factor of 10 drops/mL. The nurse would set the infusion flow rate at
- A. 16 drops/min
- B. 17 drops/min
- C. 18 drops/min
- D. 19 drops/min
Correct Answer: B
Rationale: 100 mL / 1 hour = 100 mL/hr; 100 mL/hr ? 1 hr/60 min = 1.67 mL/min; 1.67 mL/min ? 10 = 16.7 or 17 drops/min.
A nurse is caring for a client who is receiving electrolyte replacement therapy IV. When assessing the client's condition, the nurse observes signs of extravasation at the needle site. Which of the following would the nurse do next?
- A. Stop the current infusion and restart the infusion in another vein.
- B. Monitor the client's condition for signs of dizziness.
- C. Stop the IV infusion temporarily.
- D. Monitor the client's vital signs every 5 minutes.
Correct Answer: A
Rationale: On observing extravasation at the needle site, the nurse should restart the IV infusion in another vein. The nurse need not monitor the client's condition for any signs of dizziness since dizziness is not known to occur in the client due to extravasation at the needle site.
A nurse administering potassium to a client should monitor the client closely for signs of hyperkalemia if the client is concomitantly taking which of the following medications? Select all that apply.
- A. Lisinopril (Prinivil)
- B. Metoprolol (Lopressor)
- C. Spironolactone (Aldactone)
- D. Furosemide (Lasix)
- E. Hydrochlorothiazide
Correct Answer: A,C
Rationale: A nurse administering potassium to a client should monitor the client closely for signs of hyperkalemia if the client is concomitantly taking the following medications: ACE inhibitors (lisinopril) and potassium-sparing diuretics, such as spironolactone.
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 has developed electrolyte imbalances. The nurse understands that which of the following would most likely contribute to the client's current situation? Select all that apply.
- A. Vomiting
- B. Constipation
- C. Surgery
- D. Drug administration
- E. Diagnostic tests
Correct Answer: A,C,D,E
Rationale: The following can result in electrolyte imbalances in a client: vomiting, diarrhea, surgery, drug administration, and diagnostic tests.