Nokea
A nurse is caring for a client who is receiving ammonium chloride. The nurse would be alert for the development of which of the following as a possible adverse reaction?
- A. Depressed reflexes
- B. Muscle weakness
- C. Circulatory collapse
- D. Metabolic acidosis
Correct Answer: D
Rationale: The nurse should monitor the client's condition for metabolic acidosis as an adverse reaction to ammonium chloride.
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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 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 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.
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.