N221 Ch 29 NCLEX Practice Questions with Correct Answers

When caring for a patient with serum potassium of 2.8 mEq/L, which is a priority nursing intervention when administering intravenous replacement therapy? -Administer potassium as a bolus over 10 minutes. -Maintain infusion rate at no greater than 20 mEq/hr. -Apply ice packs to site of intravenous administration. -Teach the patient and family the signs and symptoms of hypokalemia. -Maintain infusion rate at no greater than 20 mEq/hr. Too rapid an infusion of potassium can cause cardiac arrhythmias. Therefore intravenous potassium infusion rates should not exceed 20 mEq/hr. When planning administration of hypertonic saline solution to treat a patient with severe hyponatremia, the nurse monitors for signs and symptoms of overdose as manifested by -lethargy and hypotension. -vomiting and diarrhea. -flushed skin and increased thirst. -confusion and seizures. -flushed skin and increased thirst. Flushed skin and increased thirst are signs and symptoms of hypernatremia. The other choices are signs and symptoms of hyponatremia. A patient receiving a unit of red blood cells suddenly develops shortness of breath, chills, and fever. Following patient assessment, what is the nurse's initial action? -Reassure the patient that this is an expected reaction. -Notify the physician while a peer monitors the blood transfusion. -Discontinue the infusion of packed cells. -Decrease the infusion rate, and reassess the patient in 15 minutes. -Discontinue the infusion of packed cells. These are signs and symptoms of a blood transfusion reaction that could escalate to anaphylaxis. Therefore it is a priority to immediately stop the blood transfusion. The nurse is caring for a patient with an acute renal insufficiency and thrombocytopenia. Along with platelet transfusions, the nurse would expect to administer which substance to increase deficient clotting factors in this patient? -Fresh frozen plasma -Albumin -Plasma protein factors -Whole blood -Fresh frozen plasma