Nokea
A nurse suspects a client receiving an infusion of potassium to replace losses due to diuretic therapy may be developing hyperkalemia. Which of the following signs or symptoms would a nurse observe? Select all that apply.
- A. Anxiety
- B. Card Delegations arrhythmias
- C. Hypertension
- D. Decreased bowel sounds
- E. Paresthesias
Correct Answer: A,B,E
Rationale: The following are signs or symptoms a nurse would observe in a client with hyperkalemia: irritability, anxiety, listlessness, mental confusion, nausea, diarrhea, abdominal distress, GI hyperactivity, paresthesias, weakness and heaviness of the legs, flaccid paralysis, hypotension, cardiac arrhythmias, and ECG changes.
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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).
A physician orders normal saline for a client to replace lost fluids due to poor oral intake. The order is for 1000 mL normal saline to be infused over a period of 6 hours. If the drop factor is 20 drops/mL, the nurse would set the IV flow rate at
- A. 55 drops/min
- B. 56 drops/min
- C. 57 drops/min
- D. 58 drops/min
Correct Answer: B
Rationale: 1000 mL / 6 hours = 166.7 mL/hr; 166.7 mL/hr ? 1 hr/60 min = 2.8 mL/min; 2.8 mL/min ? 20 = 55.5 or 56 drops/min.
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 nurse is caring for a client who is receiving ammonium chloride. The nurse would be alert for the development of which of the following as a possible adverse reaction?
- A. Depressed reflexes
- B. Muscle weakness
- C. Circulatory collapse
- D. Metabolic acidosis
Correct Answer: D
Rationale: The nurse should monitor the client's condition for metabolic acidosis as an adverse reaction to ammonium chloride.