NCLEX-PN Test #7 2

Question 1

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?

Accepted Answer

31 gtt/min

Answer

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.

Question 2

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?

Accepted Answer

Hypokalemia

Answer

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.

Question 3

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?

Accepted Answer

Stop the transfusion immediately, maintain IV access with normal saline

Answer

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).

Question 4

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

Accepted Answer

Capillary blood glucose every 4–6 hours

Answer

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.

Question 5

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

Accepted Answer

Seizure activity

Answer

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.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #7 2