Nokea
When administering intravenous electrolyte solution, the nurse should take which of the following precautions?
- A. Infuse hypertonic solutions rapidly.
- B. Mix no more than 80 mEq of potassium per liter of fluid.
- C. Prevent infiltration of calcium, which causes tissue necrosis and sloughing.
- D. As appropriate, reevaluate the client's digitalis dosage. He might need an increased dosage because IV calcium diminishes digitalis's action.
Correct Answer: C
Rationale: Preventing tissue infiltration is important to avoid tissue necrosis. Choice A is incorrect because hypertonic solutions should be infused cautiously and checked with the RN if there is a concern. Choice B is incorrect because potassium, mixed in the pharmacy per physician order, is mixed at a concentration no higher than 60 mEq/L.
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Two hours after administering iron dextran, the nurse is drawing the client's blood sample for a laboratory test. Which intervention should the nurse implement when noting that the client's blood has a brownish hue?
- A. Document the serum color.
- B. Draw blood from another site.
- C. Immediately notify the HCP.
- D. Discard the sample of blood.
Correct Answer: A
Rationale: A: The nurse should document the finding of the blood's brownish hue; iron dextran (Dexferrum) may impart a brownish hue to blood drawn within four hours after administration. B: Drawing blood from another site is unnecessary because iron dextran imparts the brown-colored serum, and the color will be unchanged even if blood is drawn at another site. C: Notifying the HCP is unnecessary because the brown-colored serum is a normal finding after iron dextran administration. D: The blood sample should not be discarded because the brown-colored serum is a normal finding after iron dextran administration and will not affect laboratory analysis.
The nurse is preparing to administer Azithromycin, and the pharmacy has provided the drug in a powder form that requires reconstitution connected to a saline piggyback. Which of the following is least concerning when preparing the medication?
- A. The expiration date on the powder vial is the same as the current date.
- B. The brand/trade name is not listed on the vial.
- C. The storage instructions on the vial says 'store at room temperature', and the vial is very cold to the touch indicating it has been taken out of a freezer.
- D. The bag of saline is leaking.
Correct Answer: B
Rationale: The brand or trade name is not required to be on the medication label if the generic name is present. The nurse should check that the medication is not expired and that it has been stored according to the storage instructions. If the saline bag is leaking, it may indicate that the container is damaged and the fluid may not be sterile.
The 17-year-old female is about to have a drug screen test for employment. The adolescent tells the nurse of a recent UTI that was treated with antibiotics. Which antibiotic, if identified by the client, could produce a false-positive urine screening test for opioids?
- A. Cephalexin
- B. Ceftazidime
- C. Amoxicillin
- D. Ciprofloxacin
Correct Answer: D
Rationale: A: Cephalexin (Keflex) does not interfere with urine testing for opioids. B: Ceftazidime (Fortaz), a cephalosporin, does not interfere with urine testing for opioids. C: Amoxicillin (Amoxil), an aminopenicillin, does not interfere with urine testing for opioids. D: Fluoroquinolones, such as ciprofloxacin (Cipro), can cause false-positive urine opiate screens.
The LPN is performing an assessment on a 4-day-old 8-pound, 6-ounce newborn with a head circumference of 33 cm. Given this information, what would the nurse expect the child's chest circumference to be?
- A. about 31 cm
- B. about 36 cm
- C. about 29 cm
- D. about 33 cm
Correct Answer: A
Rationale: In newborns, the head circumference should be 2 cm to 3 cm larger than the chest circumference. Note: Due to molding that occurs during the birth process, the head and chest measurement may be nearly equal during the first 48 hours after birth.
New medications are prescribed for the client taking lithium. Which medication, if prescribed, should the nurse question with the HCP?
- A. Isosorbide dinitrate by mouth tid
- B. Prednisone 20 mg by mouth daily
- C. Furosemide 80 mg by mouth daily
- D. Insulin aspart 2 units subcut with meals
Correct Answer: C
Rationale: Furosemide (Lasix) is a loop diuretic that promotes sodium loss and lithium retention, increasing serum lithium levels and risk of toxicity.