Nokea
The nurse is reviewing the client's laboratory data. Which current prescription should the nurse clarify with the primary healthcare provider (PHCP)?
- A. Dextrose 5% in water (D5W)
- B. dexamethasone
- C. digoxin
- D. ergocalciferol
Correct Answer: A
Rationale: D5W is hypotonic and may worsen hyponatremia, requiring clarification in a client with low sodium levels.
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The nurse is working with a client who has been diagnosed with hypervolemia. Which of the following conditions can cause hypervolemia? Select all that apply.
- A. Heart failure
- B. Renal failure
- C. Type 1 Diabetes Mellitus
- D. Third degree burns
- E. Hormonal imbalances
Correct Answer: A,B,E
Rationale: Heart failure, renal failure, and hormonal imbalances (e.g., SIADH) impair fluid excretion, causing hypervolemia.
The nurse understands that which of the following are complications of acute tubular necrosis (ATN)? Select all that apply.
- A. Metabolic acidosis
- B. High thyroxine levels
- C. Hyponatremia
- D. Decreased parathyroid levels
- E. Electrolyte imbalances
Correct Answer: A,C,E
Rationale: ATN causes metabolic acidosis, hyponatremia, and electrolyte imbalances due to impaired renal function.
The nurse is administering IV magnesium to a client with a magnesium level of 1.5 mEq/L (0.62 mmol/L) [1.5-2.5 mEq/L, 0.6-1.2 mmol/L]. You check on them halfway through the infusion, and they report that their face feels flushed. What is the priority nursing intervention?
- A. Slow down the infusion rate.
- B. Notify the primary healthcare provider (PHCP).
- C. Reassess the client when the infusion finishes.
- D. Stop the infusion.
Correct Answer: A
Rationale: Flushing is a common side effect of IV magnesium infusion and can often be managed by slowing the infusion rate to reduce symptoms. Stopping the infusion (D) or notifying the PHCP (B) is not necessary unless symptoms worsen. Reassessing later (C) delays intervention.
The nurse is reviewing the assignment for the shift and will be caring for the following clients. Which client is at risk for hypokalemia? A client with
- A. hyperemesis gravidarum.
- B. end-stage renal failure.
- C. diabetic ketoacidosis.
- D. third-degree burns.
Correct Answer: A
Rationale: Hyperemesis gravidarum causes potassium loss through vomiting, increasing hypokalemia risk.
The nurse is reviewing the assessment data for a client with acute glomerulonephritis (AGN). Which of the following would be an expected finding?
- A. Ketonuria
- B. Hematuria
- C. Polyuria
- D. Glycosuria
Correct Answer: B
Rationale: Hematuria is a hallmark of acute glomerulonephritis due to glomerular inflammation.