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 C

Explanation

A. Crush the medication and administer it through the tube: Crushing sustained-release medications can alter their release mechanism, leading to potential overdose or ineffective treatment. Sustained-release formulations should not be crushed.
B. Provide the medication orally for the client to swallow: This option is not appropriate because the client has a gastrostomy tube, and oral administration is not suitable for this route.
C. Ask the healthcare provider to prescribe the medication as an elixir for tube administration: This is the correct approach as it ensures the medication is in a form suitable for administration through the gastrostomy tube without altering its release properties.
D. Dissolve the medication in water and administer it through the tube: Dissolving sustained-release tablets is not recommended as it may compromise the medication's intended release mechanism.

A. Hypocalcemia B. Hypokalemia C. Hypophosphatemia D. Hyponatremia

Correct Answer is A

Explanation

A. Hypocalcemia: Hypocalcemia can cause signs such as muscle twitching, spasms, or tetany, which could be observed in the upper extremity and might be noted during a blood pressure measurement.
B. Hypokalemia: While hypokalemia can cause muscle weakness and cramping, it is less directly associated with specific upper extremity signs compared to hypocalcemia.
C. Hypophosphatemia: This generally affects energy levels and muscle function but is less commonly associated with immediate and visible upper extremity signs.
D. Hyponatremia: This primarily affects fluid balance and mental status, and is less likely to present with specific upper extremity findings during a blood pressure check.

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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?

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