Nokea
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.
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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 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 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 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.
After teaching a group of nursing students about plasma expanders, the instructor determines that the teaching was successful when the students identify which of the following as an example? Select all that apply.
- A. Normal saline
- B. Hetastarch
- C. Dextran
- D. D5W
- E. Albuminar/Buminate
Correct Answer: B,C
Rationale: The following are examples of plasma expanders: hetastarch (Hespan), low-molecular-weight dextran (Dextran 40), and high-molecular-weight dextran (Dextran 75).