A licensed practical/vocational nurse (LPN/LVN) is preparing to add a new IV of 5% dextrose in water (D5W) with potassium (K) to an existing line. The LPN/LVN notices that only 25 mL of urine has been collected over the past hour. What is the most appropriate nursing intervention?
Avoid hanging the IV with K and inform the registered nurse (RN) of the urine output.
Run the IV rapidly for 30 minutes to stimulate urine production.
Call the physician who ordered the K+.
Hang the IV as ordered and chart the output.
The Correct Answer is A
A. Avoid hanging the IV with K and inform the registered nurse (RN) of the urine output: The low urine output suggests potential renal impairment, which could lead to potassium retention. Administering potassium could cause dangerous hyperkalemia, so it’s important to hold the IV and consult the RN for further evaluation.
B. Run the IV rapidly for 30 minutes to stimulate urine production: Rapid infusion could worsen fluid overload or cause other complications, and it will not address the renal issue causing the low urine output. Potassium should be avoided to prevent complications.
C. Call the physician who ordered the K+: While notifying the physician is important, the immediate priority is to inform the RN, as the potassium infusion should be withheld until renal function is assessed and corrected, if necessary.
D. Hang the IV as ordered and chart the output: Hanging the IV with potassium is risky in this case, as the client may not be able to eliminate potassium due to decreased renal function. Monitoring urine output is crucial before proceeding with potassium administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Client receiving total parenteral nutrition (TPN): TPN is typically formulated with electrolytes, including potassium, but it does not inherently increase the risk of hyperkalemia unless there is an issue with kidney function or an excessive amount of potassium in the formula.
B. Client taking furosemide for chronic heart failure: Furosemide is a loop diuretic that causes the body to excrete potassium through urine, which actually puts the client at risk for hypokalemia, not hyperkalemia.
C. Client admitted for diabetic ketoacidosis (DKA): In DKA, the body produces excess acidic ketones, leading to metabolic acidosis. As a compensatory mechanism, potassium is shifted from the inside of cells into the bloodstream, leading to hyperkalemia, despite actual total body potassium depletion.
D. Client with anxiety-induced hyperventilation: Hyperventilation typically leads to respiratory alkalosis, which may cause a shift in potassium levels but does not directly cause hyperkalemia. Anxiety-induced hyperventilation is less likely to result in hyperkalemia compared to DKA.
Correct Answer is A
Explanation
A. 0.9% sodium chloride (NS): Normal saline is an isotonic solution that closely matches the osmolality of body fluids. It is the best choice to replace extracellular fluid lost from vomiting and diarrhea.
B. 0.225% sodium chloride (1/4 NS): This hypotonic solution can shift fluids into cells but is not ideal for isotonic therapy. It may cause fluid imbalance and not restore extracellular fluid balance effectively in vomiting and diarrhea.
C. 0.45% sodium chloride (1/2 NS): This is another hypotonic solution that may cause fluid shifts into the cells. It is not isotonic, making it less appropriate for fluid replacement in this case.
D. 3% sodium chloride (3% NaCl): This hypertonic solution is used for severe hyponatremia and shifts fluids out of cells. It is inappropriate for fluid replacement in vomiting and diarrhea, as it could lead to fluid overload.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.