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A nurse suspects a client receiving an infusion of magnesium may be developing hypermagnesemia based on assessment of which of the following? Select all that apply.
- A. Drowsiness
- B. Diaphoresis
- C. Hypertension
- D. Absent deep tendon reflexes
- E. Impaired respiration
Correct Answer: A,B,D,E
Rationale: Signs and symptoms of hypermagnesemia include lethargy, drowsiness, impaired respiration, flushing, diaphoresis, hypotension, and weak or absent deep tendon reflexes.
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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 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 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 teaching a client about his prescribed potassium replacement therapy. The client is to continue taking the drug orally at home. After teaching the client about this therapy, the nurse determines that additional teaching is needed when the client states which of the following?
- A. I'll take the drug immediately after a meal.
- B. I need to drink a full glass of water when I take the drug.
- C. If I have trouble swallowing the drug, I can crush it.
- D. If the pharmacy gives me a liquid form, I can mix it in cold water or juice.
Correct Answer: C
Rationale: When given orally, potassium may cause GI distress. Therefore, it is given immediately after meals or with food and a full glass of water. Oral potassium must not be crushed or chewed.
A nurse is caring for a client who has been prescribed potassium. From the client's health history, the nurse understands that the client has also been taking salt substitutes. Which of the following conditions should the nurse monitor for in this client, occurring due to the interaction of the salt substitutes with potassium?
- A. Severe hemolytic reactions
- B. Elevated serum potassium levels
- C. Acute dehydration
- D. Severe hyperkalemia
Correct Answer: D
Rationale: The nurse should monitor the client's condition for signs and symptoms of severe hyperkalemia, which occurs due to the interaction of potassium with salt substitutes.