Nokea
The use of an infusion pump or controller still requires nursing supervision and frequent monitoring of the IV infusion to monitor for signs of infiltration. Assessment of which of the following at the infusion site would lead the nurse to suspect that infiltration is occurring? Select all that apply.
- A. Edema
- B. Necrosis
- C. Burning
- D. Itching
- E. Redness
Correct Answer: A,E
Rationale: It is important for the nurse to monitor frequently for signs of infiltration while an infusion pump is in use. The signs of infiltration include edema and redness at the infusion site.
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A client is at risk for hypercalcemic syndrome. The primary health care provider prescribes additional therapy to combat this syndrome. Which of the following would the nurse expect to be prescribed? Select all that apply.
- A. Sodium chloride
- B. Potassium
- C. Furosemide
- D. Magnesium
- E. Bicarbonate
Correct Answer: A,C
Rationale: To combat hypercalcemic syndrome, the primary health care provider may prescribe IV sodium chloride and a potent diuretic such as furosemide. When used together, these two drugs markedly increase calcium renal clearance and reduce hypercalcemia.
A nurse is assigned to care for a client who has received albumin intravenously. The nurse understands that which of the following reasons has prompted the administration of plasma protein fractions to the client?
- A. The client must have lost a lot of blood volume due to severe hemorrhage.
- B. The client must have poor wound-healing abilities with a high risk of infection.
- C. The client must be experiencing a condition in which plasma alone is lost.
- D. The client must be experiencing hypovolemic shock due to trauma.
Correct Answer: D
Rationale: Plasma protein fractions are used in clients to treat hypovolemic shock that occurs as a result of burns, trauma, surgery, and infections or in conditions where shock is not currently present but likely to occur. It is also used in the case of hypoproteinemia, as might be seen in clients with nephrotic syndrome and hepatic cirrhosis, as well as other diseases or 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 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 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.