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 ["A","C","D","E"]

Explanation

A. Muscle cramps: Muscle cramps can occur due to electrolyte imbalances, such as low potassium, which are common in states of dehydration and fluid imbalance.
B. Bradycardia: Bradycardia is not typically associated with dehydration or fluid imbalance. Dehydration usually causes an increase in heart rate (tachycardia) as the body tries to maintain adequate circulation.
C. Concentrated urine: Concentrated urine is a common sign of dehydration as the kidneys conserve water, leading to reduced urine output and higher urine concentration.
D. Tachycardia: Tachycardia is a compensatory mechanism in response to decreased fluid volume, as the heart pumps faster to maintain adequate blood flow and blood pressure.
E. Increased thirst: Increased thirst is a natural response to dehydration as the body signals the need for more fluid intake to correct the fluid imbalance.

A. Total urine output 45 mL curing past 3 hours B. Nausea and vomiting C. Clear fluid leaking from insertion site D. Severe headache E. Left knee pain 3 out of 10

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}

Explanation

Total urine output 45 mL during past 3 hours: Appropriate
Rationale: Epidural anesthesia can affect bladder function, leading to reduced urine output. A total urine output of 45 mL in 3 hours is low and should be reported as it might indicate urinary retention or decreased kidney function.
Nausea and vomiting: Inappropriate
Rationale: Nausea and vomiting are not typically a direct concern related to epidural anesthesia unless they are severe or persistent. These symptoms are more commonly associated with general anesthesia or postoperative complications, but they are not immediate concerns specific to epidural block.
Clear fluid leaking from insertion site: Appropriate
Rationale: Clear fluid leaking from the epidural insertion site could indicate cerebrospinal fluid leakage or other complications. This should be reported immediately to assess for potential complications such as an epidural hematoma or infection.
Severe headache: Appropriate
Rationale: A severe headache following an epidural block could be a sign of a post-dural puncture headache, which is a known complication of epidural anesthesia. It should be reported to the healthcare provider for further evaluation and management.
Left knee pain 3 out of 10: Inappropriate
Rationale: Pain at a level of 3 out of 10 is relatively mild and may be expected following surgery. While it is important to monitor and manage pain, this level of pain is not usually an immediate concern related to the epidural anesthesia unless other symptoms are present.

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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 ["A","C","D","E"]

Explanation

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}

Explanation

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