Nokea
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.
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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 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.
The nurse should review a client's medical history prior to the administration of plasma protein factors as their administration is contraindicated in clients with which of the following? Select all that apply.
- A. Allergy to albumin
- B. Severe anemia
- C. Cardiac failure
- D. Cardiopulmonary bypass
- E. Dialysis
Correct Answer: A,B,C,D
Rationale: The nurse should review a client's medical history prior to the administration of plasma protein factors as their administration is contraindicated in the following situations: clients with allergic reaction to albumin, severe anemia, cardiac failure, or normal or increased intravascular volume or clients on cardiopulmonary bypass.
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 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.