Nokea
The nurse should review a client's medical history prior to the administration of plasma protein factors as their administration is contraindicated in clients with which of the following? Select all that apply.
- A. Allergy to albumin
- B. Severe anemia
- C. Cardiac failure
- D. Cardiopulmonary bypass
- E. Dialysis
Correct Answer: A,B,C,D
Rationale: The nurse should review a client's medical history prior to the administration of plasma protein factors as their administration is contraindicated in the following situations: clients with allergic reaction to albumin, severe anemia, cardiac failure, or normal or increased intravascular volume or clients on cardiopulmonary bypass.
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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 electrolyte replacement therapy IV. When assessing the client's condition, the nurse observes signs of extravasation at the needle site. Which of the following would the nurse do next?
- A. Stop the current infusion and restart the infusion in another vein.
- B. Monitor the client's condition for signs of dizziness.
- C. Stop the IV infusion temporarily.
- D. Monitor the client's vital signs every 5 minutes.
Correct Answer: A
Rationale: On observing extravasation at the needle site, the nurse should restart the IV infusion in another vein. The nurse need not monitor the client's condition for any signs of dizziness since dizziness is not known to occur in the client due to extravasation at the needle site.
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 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.
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.