A nurse is caring for a client with severe hypokalemia. The provider places an order for IV potassium chloride (KCI) 60 mEq x1 now. Which action should the nurse take when caring for this client?

Discontinue cardiac monitoring during the infusion.

Administer KCI as a rapid IV bolus.

Only give the KCI via a central venous line.

Infuse the KCI at a rate of 10 mEq/hour.

Answer and Explanation

The Correct Answer is C

A) Discontinue cardiac monitoring during the infusion:
Discontinuing cardiac monitoring during the infusion of potassium chloride is unsafe. Potassium infusions can significantly impact cardiac function, so continuous cardiac monitoring is necessary to detect any arrhythmias or other complications.

B) Administer KCI as a rapid IV bolus:
Administering potassium chloride as a rapid IV bolus is contraindicated due to the risk of severe adverse effects, including cardiac arrest. Potassium should be infused slowly to avoid complications.

C) Only give the KCI via a central venous line:
Potassium chloride is ideally administered through a central venous line because it is irritating to veins and can cause damage if given through a peripheral line. A central line reduces the risk of irritation and allows for safer infusion of potassium.

D) Infuse the KCI at a rate of 10 mEq/hour:
Infusing potassium chloride at a rate of 10 mEq/hour is generally too slow for an emergency situation requiring immediate correction of severe hypokalemia. For more urgent cases, higher rates may be required, but only under strict medical supervision to avoid complications.

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Correct Answer is C

Explanation

A) The client is reporting constipation:
Constipation is a common issue with enteral feeding, often due to decreased fluid intake or lack of fiber. While it is important to manage constipation to improve comfort and bowel function, it is not as urgent as dealing with vomiting.

B) The client reports being thirsty:
Thirst can be a sign of dehydration or inadequate fluid intake. Although it should be addressed to ensure proper hydration, it is less critical compared to vomiting, which poses immediate risks.

C) The client is vomiting the enteral formula:
Vomiting is a priority concern because it can lead to aspiration, dehydration, electrolyte imbalances, and further complications. Addressing the cause of vomiting and managing it promptly is crucial for the client’s safety.

D) The client is experiencing abdominal cramping:
Abdominal cramping can be related to the feeding rate, type of formula, or intolerance. While it requires attention, it is less urgent than addressing vomiting, which could have more immediate and serious consequences.

A. The first 2 min B. The final 15 min C. The first 15 min D. The final 2 min

Correct Answer is C

Explanation

A) The first 2 min: While it is essential to monitor the client closely during the first few minutes of a PRBC infusion, a two-minute observation period is insufficient to detect most acute transfusion reactions. Many reactions, such as fever, chills, and allergic responses, can take longer to manifest.

B) The final 15 min: Monitoring during the final 15 minutes is important to ensure the infusion is completed without complications. However, the most critical time for monitoring is at the beginning of the infusion, as acute reactions are more likely to occur early on.

C) The first 15 min: The first 15 minutes of a PRBC transfusion are crucial because most acute transfusion reactions, such as allergic reactions, febrile non-hemolytic reactions, and hemolytic reactions, occur within this time frame. The nurse should remain at the bedside to promptly identify and manage any adverse reactions, ensuring the client's safety.

D) The final 2 min: Monitoring during the final two minutes of the infusion is also important, but it is not the critical time frame for detecting most transfusion reactions. Observing the client closely during the initial phase of the transfusion is essential to address any immediate complications.

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A nurse is caring for a client with severe hypokalemia. The provider places an order for IV potassium chloride (KCI) 60 mEq x1 now. Which action should the nurse take when caring for this client?

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