A client has been receiving IV potassium therapy. Upon further assessment, the nurse notes the site has become erythematous and edematous. Which action by the nurse is most appropriate?

Flush the IV site with normal saline, then restart the IV potassium therapy

Discontinue the IV and restart in another site

Flush the IV site with heparin

Stop the IV site and check for blood return

Answer and Explanation

The Correct Answer is B

A. Flush the IV site with normal saline, then restart the IV potassium therapy: Flushing and restarting the infusion at the same site is not appropriate if there is redness and swelling, as these are signs of possible phlebitis or infiltration.
B. Discontinue the IV and restart in another site: This is the correct choice. Given the erythema and edema, which indicate possible complications like phlebitis or infiltration, the IV should be discontinued and restarted in a new site to prevent further complications.
C. Flush the IV site with heparin: This is not appropriate for erythema and edema and could exacerbate the problem. Heparin is used to maintain patency of IV lines, not to treat complications.
D. Stop the IV site and check for blood return: While checking for blood return is a good practice to assess for patency, the primary action should be to discontinue the IV and start a new one due to the complications at the site.

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Correct Answer is B

Explanation

A. Midazolam (Versed): This is a benzodiazepine used for sedation. It is not typically used in the post-anesthesia care unit unless there is a need for additional sedation or anxiolysis, which is not indicated based on the scenario.
B. Naloxone (Narcan): This is the correct choice. Naloxone is used to reverse opioid-induced respiratory depression. If the vital signs indicate respiratory depression or decreased oxygen saturation potentially due to opioid medications used during surgery, naloxone would be administered.
C. Atropine (Atropen): This medication is used to treat bradycardia (slow heart rate) and is not typically indicated based on vital signs trends without specific symptoms.
D. Dantrolene (Dantrium): This medication is used to treat malignant hyperthermia, a rare but serious condition often triggered by certain anesthetics. It would be indicated if there were signs of this condition, such as a high fever and muscle rigidity, which is not mentioned in the scenario.

A. A 47-year-old client who reports two loose stools with a serum sodium of 139 mmol/L B. A 71-year-old client with a calcium level of 8.9 mg/dL and a negative Trousseau sign C. A 52-year-old client with fluid volume excess and BUN of 18 mg/dL D. A 60-year-old client with a serum potassium of 3.2 mEq/L and heart palpitations

Correct Answer is D

Explanation

A. A 47-year-old client who reports two loose stools with a serum sodium of 139 mmol/L: Although diarrhea can lead to electrolyte imbalances, a serum sodium level of 139 mmol/L is within normal range, so this client is not the highest priority.
B. A 71-year-old client with a calcium level of 8.9 mg/dL and a negative Trousseau sign: A calcium level of 8.9 mg/dL is slightly low but not critically low, especially with a negative Trousseau sign. This client is stable compared to others.
C. A 52-year-old client with fluid volume excess and BUN of 18 mg/dL: A BUN of 18 mg/dL indicates mild elevation, and fluid volume excess can be managed with adjustments in treatment; this client does not require immediate priority.
D. A 60-year-old client with a serum potassium of 3.2 mEq/L and heart palpitations: A potassium level of 3.2 mEq/L indicates hypokalemia, which can cause serious cardiac issues and symptoms like palpitations. This client requires urgent attention to address the potential risk of cardiac complications.

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A client has been receiving IV potassium therapy. Upon further assessment, the nurse notes the site has become erythematous and edematous. Which action by the nurse is most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse working on a medical surgical unit is assigned four clients at the start of their shift. What client should be given the highest priority?

Correct Answer is D

Explanation

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