Nokea
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.
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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 client is prescribed total parenteral nutrition due to weight loss secondary to cancer treatment. The nurse would most likely identify which nursing diagnosis as the priority?
- A. Risk for Injury
- B. Imbalanced Nutrition: Less Than Body Requirements
- C. Deficient Fluid Volume
- D. Risk for Decreased Cardiac Output
Correct Answer: B
Rationale: The need for total parenteral nutrition would support the nursing diagnosis of Imbalanced Nutrition: Less Than Body Requirements to help promote weight gain and nutritional stability.
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 is prescribed bicarbonate. The client's medication history reveals that the client is also taking fluoroquinolones. The nurse would be alert for the development of which of the following due to an interaction of these two drugs?
- A. Respiratory alkalosis
- B. Severe abdominal pain
- C. Increased risk of crystalluria
- D. Renal impairment
Correct Answer: C
Rationale: The nurse should monitor the client's condition for an increased risk of crystalluria as a result of the interaction of fluoroquinolones and bicarbonate.
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.