IV potassium chloride (KCl) 60 mEq is prescribed for a 49-year-old female patient with severe hypokalemia. Which action should the nurse take?
Infuse the KCl at a maximum rate of 10 mEq/hr.
Discontinue cardiac monitoring during the infusion.
Administer the KCl as a rapid IV bolus.
Refuse to give the KCl through a peripheral venous line.
The Correct Answer is A
Choice A: Infuse the KCl at a maximum rate of 10 mEq/hr
This is the correct answer. The recommended infusion rate for potassium chloride is generally not to exceed 10 mEq per hour to avoid complications such as hyperkalemia and cardiac arrhythmias. This rate ensures that the potassium is administered safely and effectively, allowing for proper monitoring and adjustment if necessary.
Choice B: Discontinue cardiac monitoring during the infusion
This choice is incorrect. Cardiac monitoring is essential during the infusion of potassium chloride, especially in patients with severe hypokalemia, due to the risk of arrhythmias and other cardiac complications. Continuous monitoring allows for the early detection of any adverse effects and timely intervention.
Choice C: Administer the KCl as a rapid IV bolus
Administering potassium chloride as a rapid IV bolus is dangerous and contraindicated. Rapid infusion can lead to severe hyperkalemia, which can cause fatal cardiac arrhythmias. Potassium chloride should always be administered slowly and diluted in an appropriate volume of fluid.
Choice D: Refuse to give the KCl through a peripheral venous line
While central lines are preferred for higher concentrations of potassium chloride due to the risk of irritation and phlebitis, peripheral lines can be used for lower concentrations and slower infusion rates. Refusing to administer potassium chloride through a peripheral line is not necessary if the infusion is properly managed and monitored.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Apply wrist restraints to secure IV lines
Applying wrist restraints to secure IV lines should not be the first action. Restraints are generally considered a last resort due to their potential to cause harm and distress. They should only be used when absolutely necessary and after other interventions have failed. In this scenario, the patient’s agitation and confusion could be due to hypoxia, and addressing the underlying cause is more important than immediately resorting to restraints.
Choice B: Administer the prescribed opioid
Administering the prescribed opioid is not the first action to take. While pain management is crucial, opioids can sometimes exacerbate confusion and agitation, especially in the immediate postoperative period. It is essential to first assess the patient’s vital signs and oxygen levels to rule out hypoxia or other complications before administering any medication.
Choice C: Take the blood pressure and pulse
Taking the blood pressure and pulse is important but not the immediate first action. While these vital signs provide critical information about the patient’s cardiovascular status, checking the oxygen saturation is more urgent in this context. Hypoxia can lead to agitation and confusion, and addressing it promptly can stabilize the patient more effectively.
Choice D: Check the oxygen (O2) saturation
Checking the oxygen (O2) saturation should be the first action. Hypoxia is a common cause of postoperative agitation and confusion. By assessing the patient’s oxygen levels, the nurse can quickly determine if supplemental oxygen is needed, which can help alleviate the patient’s symptoms and prevent further complications. Ensuring adequate oxygenation is a priority in the immediate postoperative period.
Correct Answer is ["B","C"]
Explanation
Choice A: Hyponatremia - Dehydration
Hyponatremia occurs when the sodium levels in the blood are abnormally low. While dehydration can contribute to hyponatremia, it is not the most common cause. Hyponatremia is more frequently caused by conditions that lead to an excess of water in the body, diluting the sodium levels. These conditions include heart failure, kidney disease, and the syndrome of inappropriate antidiuretic hormone secretion (SIADH).
Choice B: Hypomagnesemia - Chronic alcoholism
This is a correct pairing. Hypomagnesemia, or low magnesium levels in the blood, is often associated with chronic alcoholism. Alcoholism can lead to poor dietary intake of magnesium, increased urinary excretion of magnesium, and gastrointestinal losses due to vomiting and diarrhea. These factors contribute to the development of hypomagnesemia in individuals with chronic alcoholism.
Choice C: Hyperkalemia - Kidney failure
This is also a correct pairing. Hyperkalemia, or high potassium levels in the blood, is commonly caused by kidney failure. The kidneys are responsible for excreting excess potassium from the body. When the kidneys are not functioning properly, they cannot remove potassium efficiently, leading to its accumulation in the blood. Other causes of hyperkalemia include certain medications, such as potassium-sparing diuretics, and conditions that cause cellular breakdown, such as rhabdomyolysis.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today