NCLEX-PN Test #7 2 Flashcards

A client with severe dehydration is ordered 1 liter of 0.9% NaCl IV to infuse over 8 hours. The IV tubing drop factor is 15 gtt/mL. What is the correct flow rate in gtt/min?

Answer: 31 gtt/min

Flow rate (gtt/min) = Volume (mL) × Drop factor ÷ Time (min). = 1000 mL × 15 gtt/mL ÷ 480 min = 15,000 ÷ 480 = 31.25, rounded to 31 gtt/min. Accurate IV flow rate calculation is essential to prevent fluid overload or inadequate rehydration.

The PN assesses a client and finds shallow respirations, muscle weakness, and a serum potassium of 2.9 mEq/L. Which condition does this represent?

Answer: Hypokalemia

Hypokalemia (K+ < 3.5 mEq/L) presents with muscle weakness, fatigue, leg cramps, shallow respirations (respiratory muscle weakness), constipation, and cardiac dysrhythmias. It is commonly caused by diuretic use, vomiting, or diarrhea. Hyperkalemia causes peaked T waves and muscle weakness with opposite cardiac effects.

A client is receiving a blood transfusion and develops chills, fever, and low back pain 15 minutes into the infusion. What is the priority nursing action?

Answer: Stop the transfusion immediately, maintain IV access with normal saline

These symptoms indicate an acute hemolytic transfusion reaction, the most dangerous type, caused by ABO incompatibility. The priority is to STOP the transfusion immediately, then maintain IV access with a new line and 0.9% NaCl, notify the provider and blood bank, and monitor vital signs and urine output (hemoglobinuria).

A client is receiving total parenteral nutrition (TPN). Which nursing assessment is most important for monitoring metabolic complications?

Answer: Capillary blood glucose every 4–6 hours

TPN contains high concentrations of dextrose, which can cause hyperglycemia. Blood glucose monitoring every 4–6 hours (or per protocol) is the most critical metabolic monitoring in TPN clients. Hyperglycemia impairs immune function and can cause osmotic diuresis. Insulin may be added to the TPN bag or given as sliding-scale coverage.

The nurse is caring for a client with a serum sodium of 122 mEq/L. Which finding requires immediate attention?

Answer: Seizure activity

Severe hyponatremia (Na+ < 125 mEq/L) causes cerebral edema due to osmotic fluid shifts into brain cells. Seizures, altered consciousness, and coma are neurological emergencies. Immediate notification of the provider and treatment with hypertonic saline (3% NaCl) under careful monitoring is required.

The PN is caring for a post-operative client with a Jackson-Pratt (JP) drain. The output for the past 8 hours is 250 mL of bright red blood. What is the priority action?

Answer: Notify the surgeon immediately

While some sanguineous drain output is expected post-operatively, 250 mL of bright red blood in 8 hours is excessive and may indicate active hemorrhage. The priority is to notify the surgeon immediately for further evaluation. Normal drain output transitions from sanguineous to serosanguineous within the first 24–48 hours.