The nurse examines the electrocardiogram (ECG) tracing of a client and notes tall T waves. What electrolyte imbalance should the nurse suspect?
a. Hypokalemia
b. Hypophosphotemia
c. Hyperkalemia
d. Hypercalcemia
Question 2
A patient's vital signs prior to a blood transfusion were: T = 97.6F (36.4C); P = 72 beats/min; R = 22 breaths/min; and BP = 132/76 mm Hg.
Twenty minutes after the transfusion was begun, the patient began complaining of feeling itchy and hot. The nurse discovered a rash on the patient's trunk. Vital signs were T = 100.8F (38.2C); P = 82 beats/min; R = 24 breaths/min; BP = 146/88 mm Hg. Based on these findings, what is the priority intervention?
a. Administer an antihistamine (antiallergenic) medication.
b. Flush the blood tubing with D5W immediately.
c. Prepare for emergency resuscitation.
d. Stop the blood transfusion immediately.
A nurse adjusts the rate of a client’s IV.
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