A nurse is assessing an older adult client who is receiving IV therapy. The nurse should recognize that which of the following findings indicates fluid volume excess? (Select all that apply.)
Crackles upon auscultation
Bounding pulse
Pitting edema
Swelling at the IV site
Urine-specific gravity greater than 1.030
Correct Answer : A,B,C
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["125"]
Explanation
To determine the mL/hr rate for the IV pump, we need to calculate the infusion rate of the
potassium chloride solution. Given:
Potassium chloride concentration: 40 mEq in 500 mL Infusion rate: 10 mEq/hr
We can set up a proportion to find the mL/hr rate:
(40 mEq / 500 mL) = (10 mEq / x mL) Cross-multiplying the equation:
40 mEq * x mL = 500 mL * 10 mEq Simplifying:
40x = 5000
Dividing both sides by 40:
x = 5000 / 40
x ≈ 125
Therefore, the nurse should set the IV pump to deliver approximately 125 mL/hr.
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.
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