A newly hired nurse is preparing to remove a client's IV catheter. Which of the following actions should the nurse take?

Ask an assistive personnel (AP) to verbalize the steps for removing an IV catheter.

Research how to remove an IV catheter from the internet.

Find an article in a nursing journal that is less than 5 years old on how to remove IV catheters.

Review the facility's policies and procedures manual about removing IV catheters.

Answer and Explanation

The Correct Answer is D

A. While an assistive personnel (AP) might assist with some tasks, they are not typically responsible for providing detailed procedural guidance on medical tasks. The nurse should seek guidance from established protocols and trained professionals.

B. While online resources can be helpful, they might not reflect the specific protocols or best practices of the facility. It's crucial to follow the facility’s policies and procedures to ensure consistency and compliance with organizational standards.

C. While reviewing current literature is beneficial for understanding best practices, the most immediate and relevant source of information is the facility's own policies and procedures. These documents will reflect the specific protocols that the facility requires.

D. Reviewing the facility's policies and procedures manual ensures that the nurse follows the specific guidelines and standards set by the institution. This approach aligns with organizational requirements and helps ensure that the procedure is performed correctly and safely within the context of the facility’s protocols.

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Correct Answer is C

Explanation

Correct answer: C

A. This action would be appropriate if the potassium level were high, indicating hyperkalemia. However, since the client's potassium level is low, the nurse should administer the KCl as prescribed to address the hypokalemia. If there are any concerns about the rate or method of administration, or if the client shows signs of potassium-related complications, the nurse should then consult the provider.

B.Calling the lab to verify the client's results may seem like a reasonable action, but it's not the most appropriate in this scenario. Serum potassium levels are commonly measured accurately, and the nurse should prioritize clinical judgment based on the current potassium level in conjunction with the client's condition and medication regimen.

C. A serum potassium level of 3.2 mEq/L is below the normal range (3.5-5.0 mEq/L), indicating hypokalemia. Hypokalemia can have serious consequences, including muscle weakness, cardiac arrhythmias, and other complications. Administering potassium chloride (KCl) as prescribed is necessary to correct this deficiency and prevent potential adverse effects associated with low potassium levels.

D.Simply omitting the KCL dose without informing the healthcare provider of the client's low potassium level could lead to a missed opportunity for appropriate intervention. Documenting the omission is essential for accurate record-keeping, but it's crucial to communicate the situation to the provider for further guidance.

A. Call the lab to verify the client's results. B. Call the prescribing physician and inform her of the client's serum potassium level results. C. Give the ordered KCL as prescribed. D. Omit the KCL dose and document it was not given.

Correct Answer is B

No explanation

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A newly hired nurse is preparing to remove a client's IV catheter. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer potassium chloride (KCL) to a client who is receiving diuretic therapy. The nurse reviews the client's serum potassium level results and discovers the client's potassium level is 3.2 mEq/L. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who has a prescription for potassium chloride (KCL) 20 mEq PO daily. The nurse reviews the client's most recent laboratory results and finds the client's potassium level is 5.2 mEq/L. Which of the following actions should the nurse take?

Correct Answer is B

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