A nurse is caring for a client who had IV fluids initiated at 0330. The IV fluids are infusing at 120 mL/hr. The nurse should record how many mL of IV fluids on the intake record at 0600?

Answer and Explanation

The Correct Answer is ["300"]

To calculate the volume of IV fluids infused from 0330 to 0600, you would determine the number of hours that have passed.

From 0330 to 0600 is 2.5 hours. Since the IV is infusing at 120 mL/hr, you would multiply the infusion rate by the number of hours. So, 120 mL/hr * 2.5 hours = 300 mL.

Therefore, the nurse should record 300 mL of IV fluids on the intake record at 0600.

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Correct Answer is B

Explanation

A. This statement suggests symptoms of vitamin B12 deficiency or glossitis, which are not typical signs of digoxin toxicity. Therefore, it is unlikely to indicate digoxin toxicity.
B. Blurred vision is a common neurological symptom of digoxin toxicity. It occurs due to disturbances in visual acuity and color vision, which can manifest as seeing halos around lights or difficulty focusing. Therefore, this statement is indicative of potential digoxin toxicity.
C. Weight gain can occur due to fluid retention, which is a symptom of heart failure rather than digoxin toxicity. Digoxin toxicity typically presents with neurological and gastrointestinal symptoms rather than weight gain.
D. Constipation is not typically associated with digoxin toxicity. Gastrointestinal symptoms such as nausea, vomiting, and anorexia are more common with digoxin toxicity, but constipation is not a specific indicator.

A. Metabolic alkalosis B. Respiratory alkalosis C. Metabolic acidosis D. Respiratory acidosis

Correct Answer is D

Explanation

A. Metabolic alkalosis is characterized by an increase in bicarbonate (HCO3-) levels in the blood, resulting in an elevated pH (>7.45). Shallow respirations are less likely to cause metabolic alkalosis directly.
B. This is not likely the initial risk. Respiratory alkalosis occurs due to hyperventilation, leading to excessive elimination of CO2 (carbon dioxide), which raises the blood pH (>7.45). Shallow respirations typically result in retention of CO2, leading to respiratory acidosis rather than alkalosis.
C. Metabolic acidosis occurs when there is an increase in acid (decreased pH <7.35) or a decrease in bicarbonate levels in the blood. Shallow respirations can lead to hypoventilation and retention of CO2, resulting in respiratory acidosis initially.
D. Shallow respirations at a rate of 9 breaths per minute reduce the elimination of CO2, leading to its accumulation in the blood. This accumulation lowers the blood pH (<7.35), causing respiratory acidosis. Therefore, the client is initially at risk for developing respiratory acidosis due to ineffective ventilation.

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A nurse is caring for a client who had IV fluids initiated at 0330. The IV fluids are infusing at 120 mL/hr. The nurse should record how many mL of IV fluids on the intake record at 0600?

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Naxlex Comprehensive Predictor Exams

A nurse in a clinic is caring for a client who has a prescription for digoxin. Which of the following statements indicates the client is experiencing digoxin toxicity?

Correct Answer is B

Explanation

A nurse is caring for a client who is postoperative and whose respirations are shallow and 9/min. Which of the following acid-based imbalances should the nurse identify the client as being at risk for developing initially?

Correct Answer is D

Explanation

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