During a clinical rotation on an orthopedic unit, a nursing student is caring for a 67-year-old patient who has undergone a knee replacement. The patient is complaining of pain at the IV site. The nursing student assesses the site and finds that the site is cool, blanched and slightly swollen. The student stops the IV and reports the situation to the nurse. What does the nursing student suspect?

Infiltration

Local inflammation

Thrombophlebitis

Phlebitis

Answer and Explanation

The Correct Answer is A

A. Infiltration occurs when IV fluid or medication leaks into the surrounding tissues rather than entering the vein. Coolness, blanching (pale appearance), swelling, and discomfort at the IV site are common signs of infiltration.

B. Local inflammation at the IV site can occur due to irritation or infection. Redness, warmth, swelling, tenderness, and possibly purulent drainage (pus) are typical signs. The description of a cool and blanched IV site does not fit the typical signs of inflammation, which usually involve warmth and redness.

C. Thrombophlebitis is inflammation of a vein with associated blood clot formation. Pain, warmth, redness, and swelling along the path of the vein are common. Thrombophlebitis typically presents with warmth and redness at the site, whereas the cool and blanched appearance described by the student suggests fluid infiltration rather than a thrombus causing inflammation.

D. Phlebitis is inflammation of the vein itself. Pain, redness, warmth, and swelling directly over the vein. Phlebitis usually manifests with warmth and redness, which are not present in the described symptoms.

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Correct Answer is A

Explanation

A. Pantoprazole belongs to a class of medications called proton pump inhibitors (PPIs), which work by reducing the production of gastric acid in the stomach. This helps in treating conditions such as gastroesophageal reflux disease (GERD) and heartburn effectively.

B. Pantoprazole is not known to cause hyperkalemia. Hyperkalemia is a condition characterized by high levels of potassium in the blood, and it is typically associated with certain medications (e.g., potassium- sparing diuretics) or medical conditions affecting kidney function. Pantoprazole's primary side effects relate to its effects on gastric acid production and absorption of certain nutrients.

C. While pantoprazole is usually taken once daily, the timing of administration is typically in the morning, before a meal. This helps to maximize its effectiveness in reducing gastric acid secretion when the stomach acid production is at its highest.

D. Pantoprazole should be taken on an empty stomach, at least 30 minutes before a meal. This timing allows the medication to be absorbed properly and work effectively to reduce gastric acid production.

A. Hypercalcemia B. Hyperglycemia C. Hypovolemia D. Hypokalemia

Correct Answer is B

Explanation

B. Dextrose 10% in water is a solution that contains a high concentration of glucose (dextrose). Infusing D10W can lead to an increase in blood glucose levels, especially if the client's body cannot metabolize the glucose effectively (e.g., in diabetic patients or those with impaired glucose tolerance).

A. Dextrose 10% in water does not contain calcium. Hypercalcemia refers to elevated calcium levels in the blood, which can occur due to various causes such as hyperparathyroidism or excessive vitamin D intake, but not from D10W infusion.

C. Dextrose 10% in water is not used to treat hypovolemia (low blood volume). It is a solution primarily used to provide calories and prevent ketosis rather than to expand circulating blood volume.

D. Dextrose 10% in water does not contain potassium. Hypokalemia (low potassium levels) can occur due to various reasons such as diuretic use, gastrointestinal losses, or inadequate intake, but it is not directly related to D10W infusion.

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Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has a new prescription for pantoprazole for heartburn. Which of the following information should the nurse include?

Correct Answer is A

Explanation

A nurse is assisting with the care of a client who is receiving an IV infusion of dextrose 10% in water. The nurse should monitor the client for which of the following adverse effects?

Correct Answer is B

Explanation

A nurse observes a newly licensed nurse administer enoxaparin subcutaneously using a pre- filled syringe. Which of the following indicates appropriate medication administration?

A nurse is preparing to administer a subcutaneous injection to a client. Which of the following actions should the nurse plan to take?

A nurse is reinforcing teaching with a client who has a duodenal ulcer and has a new prescription for sucralfate. Which of the following instructions should the nurse include?

A nurse is evaluating the 24-hr 1&O records of several clients. Which of the following client findings indicates an acceptable fluid balance?

A nurse is preparing to administer the hepatitis B vaccine to a client. Which of the following techniques should the nurse use to locate the deltoid muscle?

A nurse is assisting with supervising a newly licensed nurse replace a short-peripheral IV device for a client. Which of the following actions by the new nurse indicates an understanding of the procedure?

A 22-year-old dialysis patient presents to the ER with chest pain and palpitations. Laboratory tests reveal a Potassium (K+) level of 7.0 mEq/L. Which electrolyte imbalance is the patient suffering from?

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