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. "Weigh yourself every morning and every night.": While weight monitoring is important in conditions like fluid retention, hypernatremia is related to sodium levels, not fluid retention. The nurse should focus more on sodium intake than daily weight checks.
B. "Check your radial pulse twice a day.": Checking the radial pulse might be helpful for monitoring heart rate or signs of dehydration, but it does not directly address the management of hypernatremia. Focusing on sodium intake is more relevant.
C. "Read food labels to determine sodium content.": Sodium intake is a key factor in managing hypernatremia. Teaching the client to read food labels will help them identify foods high in sodium, which is critical to controlling their sodium levels and preventing worsening hypernatremia.
D. "Bake or grill the meat rather than frying it.": While baking or grilling meat is a healthier cooking method, it does not address the management of hypernatremia. Reducing sodium intake through food choices is more directly related to managing this condition.
Correct Answer is ["100"]
Explanation
Calculation:
Total volume to be infused = 50 mL.
Infusion time in minutes = 30 minutes.
Tubing drop factor = 60 gtt/mL.1
- Calculate the flow rate in drops per minute (gtt/min).
Flow rate (gtt/min) = (Total volume (mL) × Tubing drop factor (gtt/mL)) / Infusion time (min)
= (50 mL × 60 gtt/mL) / 30 min
= 3000 / 30 gtt/min
= 100 gtt/min.
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