Nokea
A nurse is caring for a client who is to receive potassium replacement. The provider's prescription reads, 'Potassium chloride 30 mEq in 0.9% sodium chloride 100 mL IV over 30 min.' Which of the following reasons should the nurse clarify this prescription with the provider?
- A. Potassium chloride should be diluted in dextrose 5% in water.
- B. The potassium infusion rate is too rapid.
- C. Another formulation of potassium should be given IV.
- D. The client should be treated by giving potassium by IV bolus.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Potassium chloride infusion rate should not exceed 10 mEq/hr to prevent hyperkalemia and cardiac arrhythmias.
2. In this case, 30 mEq in 100 mL over 30 min exceeds the safe rate.
3. Clarification is needed to adjust the infusion rate to avoid potential harm.
4. Other choices are incorrect as dextrose dilution, different formulations, and IV bolus are not the primary concerns.
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A home health nurse is visiting a client who has heart failure and a prescription for furosemide. The nurse identifies that the client has gained 2.5 kg (5 lb.) since the last visit 2 days ago. Which of the following actions should the nurse take first?
- A. Encourage the client to dangle the legs while sitting in a chair
- B. Teach the client about foods low in sodium
- C. Determine medication adherence by the client
- D. Notify the provider of the client's weight gain
Correct Answer: D
Rationale: The correct answer is D: Notify the provider of the client's weight gain. This is the first action the nurse should take because sudden weight gain in a client with heart failure could indicate fluid retention, which may worsen the client's condition. By notifying the provider, the nurse can ensure timely intervention to adjust the medication or treatment plan. Encouraging leg dangling (A) may help with circulation but does not address the immediate concern of weight gain. Teaching about low-sodium foods (B) is important for long-term management but not the priority at this moment. Determining medication adherence (C) is important but should come after addressing the immediate weight gain issue.
A client who has active tuberculosis and is taking rifampin reports that his urine and sweat have developed a red tinge. Which of the following actions should the nurse take?
- A. Check the client's liver function test results.
- B. Instruct the client to increase his fluid intake.
- C. Document this as an expected finding.
- D. Prepare the client for dialysis.
Correct Answer: C
Rationale: Rationale for Correct Answer (C): Document this as an expected finding. Rifampin is known to cause harmless discoloration of bodily fluids like urine and sweat. This is a common side effect and does not indicate any serious issues. The nurse should document this finding to track the client's response to the medication and educate the client about it.
Summary of Incorrect Choices:
A: Checking liver function test results is not necessary for the red discoloration caused by rifampin.
B: Increasing fluid intake will not resolve the red tinge as it is a known side effect of rifampin.
D: Dialysis is not indicated for the harmless discoloration caused by rifampin.
A nurse is providing teaching to a client who has a new prescription for enoxaparin. Which of the following medications for pain relief should the nurse include in the teaching that can be taken concurrently with enoxaparin?
- A. Ibuprofen
- B. Naproxen sodium
- C. Acetaminophen
- D. Aspirin
Correct Answer: C
Rationale: Rationale: Acetaminophen is the correct choice because it does not have an antiplatelet effect like aspirin, ibuprofen, and naproxen sodium. Enoxaparin is an anticoagulant that works by preventing blood clots, so it is safer to take acetaminophen for pain relief as it does not increase the risk of bleeding. Aspirin, ibuprofen, and naproxen sodium can increase the risk of bleeding when taken with enoxaparin due to their antiplatelet effects. Therefore, acetaminophen is the safest option for pain relief while on enoxaparin therapy.
A nurse is monitoring laboratory values for a client who has chronic heart failure and is receiving digoxin. Which of the following values should the nurse report to the provider?
- A. Sodium 1.38 mEq/dL
- B. Magnesium 1.5 mEq/L
- C. BUN level 10 mg/dL
- D. Potassium 2.9 mEq/L
Correct Answer: D
Rationale: The correct answer is D: Potassium 2.9 mEq/L. Low potassium levels can predispose the client to digoxin toxicity, leading to potentially life-threatening arrhythmias. Hypokalemia increases the risk of digoxin binding to cardiac tissue, enhancing its toxic effects. The nurse should report this value to the provider immediately for prompt intervention to prevent complications.
Incorrect Choices:
A: Sodium 1.38 mEq/dL - Low sodium levels are not directly related to digoxin toxicity.
B: Magnesium 1.5 mEq/L - While magnesium levels are important for cardiac function, they are not as directly linked to digoxin toxicity as potassium.
C: BUN level 10 mg/dL - BUN levels are not specific indicators of digoxin toxicity.
Summary: Potassium levels are crucial to monitor in clients taking digoxin due to the risk of toxicity. Sodium, magnesium, and BUN levels are important but not as
A nurse is reviewing the laboratory data of a client prior to administering IV tobramycin. Which of the following laboratory values should the nurse report to the provider?
- A. Sodium 137 mEq/L
- B. Hct 4.3%
- C. Hgb 15 g/dL
- D. Creatinine 2.5 mg/dL
Correct Answer: D
Rationale: The correct answer is D: Creatinine 2.5 mg/dL. Elevated creatinine levels indicate potential kidney dysfunction, which is crucial when administering nephrotoxic medications like tobramycin to prevent further kidney damage. Elevated creatinine levels can lead to drug accumulation, increasing the risk of toxicity.
Choice A (Sodium 137 mEq/L) is within normal range and not directly related to tobramycin administration. Choices B (Hct 4.3%) and C (Hgb 15 g/dL) are related to red blood cell levels and not specifically relevant to tobramycin administration. Therefore, they do not need immediate reporting.