A nurse is caring for a client who is receiving an intravenous potassium infusion and who has a urine output of 10 mL/hr and a blood urea nitrogen of 50 mg/dL (10 to 20 mg/dL). Which of the following actions should the nurse take?
Obtain a prescription for furosemide.
Prepare the client for a urine culture and sensitivity.
Discontinue the potassium infusion.
Perform a bladder scan.
The Correct Answer is C
A. Obtain a prescription for furosemide: Administering a diuretic like furosemide could worsen hypovolemia or kidney injury if the client is already oliguric. It is not the first action when potassium is accumulating due to impaired renal excretion.
B. Prepare the client for a urine culture and sensitivity: While a UTI could contribute to kidney dysfunction, the immediate concern is elevated potassium in the context of severely reduced urine output, making infection screening secondary.
C. Discontinue the potassium infusion: The client has oliguria and elevated BUN, indicating impaired renal function. Continuing potassium infusion could lead to hyperkalemia and life-threatening cardiac complications. Stopping the infusion is the priority action to prevent toxicity.
D. Perform a bladder scan: A bladder scan assesses for urinary retention, which could contribute to low urine output. However, the elevated BUN suggests intrinsic kidney impairment, making discontinuing potassium more urgent than assessing retention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Inform the nursing manager: While notifying the manager is important for accountability and support, it does not address the immediate safety needs of the client.
B. Monitor the client's condition: The first action after a medication error is to assess and monitor the client for any adverse effects. Ensuring the client’s safety and identifying early signs of complications takes priority over reporting.
C. Notify the client's provider: The provider should be informed promptly, but only after assessing the client and determining their current condition and any immediate interventions needed.
D. Complete an occurrence report: Documenting the error is essential for legal and quality improvement purposes, but it is not the first priority. The client’s safety must be addressed before reporting the incident.
Correct Answer is D
Explanation
A. Loss of consciousness: Adenosine can cause transient lightheadedness or dizziness, but complete loss of consciousness is not an expected effect during administration. Any syncope would be brief and uncommon.
B. Conversion of atrial fibrillation: Adenosine is effective for terminating paroxysmal supraventricular tachycardia (PSVT) but does not convert atrial fibrillation or atrial flutter. Its action is specific to AV node–dependent reentrant tachycardias.
C. Increased heart rate: Adenosine typically slows conduction through the AV node and may transiently slow the heart rate. An increase in heart rate is not an expected pharmacologic effect.
D. A period of asystole: Adenosine briefly blocks AV nodal conduction, which can result in a transient period of asystole lasting a few seconds. This effect is anticipated and resolves quickly, restoring normal sinus rhythm in PSVT.
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