N221 Ch 29 NCLEX Practice Questions and Solutions

A patient with severe trauma is admitted to the intensive care unit. The patient has received 5000 mL of normal saline, is exhibiting peripheral edema, and remains hypotensive. The nurse anticipates administering which substance to correct fluid balance? -Ringer's lactate -A 3% saline solution -hetastarch (Hespan) -D5W -hetastarch (Hespan) The patient needs to increase intravascular fluid volume. Hetastarch will enable this since it is a colloid that will increase osmotic pull from the extravascular spaces to the intravascular area. A 3% saline solution is also hypertonic, but its use is not preferred secondary to risk of hypernatremia. 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.