The client is receiving a liter of 0.9% sodium chloride with potassium chloride (KCI) 30 mEq IV to infuse over 4 hours. Which nursing action has the highest priority for this client?

Maintain continuous cardiac monitoring.

Monitor urinary output.

Check a serum potassium level postinfusion.

Obtain vital signs every 2 hours.

Answer and Explanation

The Correct Answer is A

A. Potassium affects the electrical activity of the heart, and abnormal potassium levels can lead to serious cardiac arrhythmias or other complications. Continuous cardiac monitoring is crucial when administering potassium chloride because it helps detect any arrhythmias or changes in heart function that might be caused by changes in potassium levels.
B. Monitoring urinary output is important because adequate urine output helps assess kidney function and ensures that potassium is being excreted properly. While monitoring urinary output is important, it is secondary to immediate cardiac monitoring during the infusion.
C. Checking the serum potassium level after the infusion is important to confirm that potassium levels have normalized or stayed within the target range. However, this action is not as immediate as continuous cardiac monitoring during the infusion.
D. Regular monitoring of vital signs is important to assess overall client stability and detect any systemic changes. However, obtaining vital signs every 2 hours might not be as critical as continuous cardiac monitoring when administering potassium.

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Correct Answer is A

Explanation

A. The development of a fever and dyspnea in a client receiving continuous tube feeding could indicate a serious complication, such as aspiration pneumonia, infection, or another significant issue. Reporting these findings to the healthcare provider is crucial for further assessment, diagnosis, and intervention.
B. While monitoring electrolyte values is important in clients receiving tube feedings, especially if there are concerns about dehydration or imbalances, it is not the immediate priority in this scenario. The client's fever and dyspnea suggest an acute issue that needs prompt attention, and addressing the acute symptoms and reporting them to the healthcare provider takes precedence over reviewing electrolytes.
C. An incentive spirometer is useful for improving lung function and preventing atelectasis, particularly in postoperative or immobile patients. However, the presence of fever and dyspnea could indicate a more urgent problem such as aspiration or infection, which requires immediate medical evaluation and intervention.
D. Connecting the tube to low intermittent suction is typically used to decompress the stomach in cases of gastric distension or to prevent aspiration of gastrointestinal contents. However, in the context of the client's new onset of fever and dyspnea, this action does not directly address the potential underlying cause, which could be more serious.

A. Document the event in the electronical health record. B. Complete an incident report. C. Inform the nurse on the next shift. D. Notify the healthcare provider.

Correct Answer is B

Explanation

A. Document in the EHR: While documenting the event in the electronic health record is important, it's not sufficient to address the medication error. An incident report provides a more comprehensive and structured approach to documenting and investigating the event.
B. When a medication error occurs, it's crucial to document the event through an incident report. This helps to identify the root cause of the error, prevent similar occurrences in the future, and ensure patient safety. An incident report should include a detailed description of the event, the actions taken, and any potential contributing factors.
C. While informing the next shift is important for continuity of care, it's not the most immediate action needed to address the medication error. Completing an incident report is a higher priority.
D. Notifying the healthcare provider is important, but it should be done in conjunction with completing an incident report. The incident report provides a detailed record of the event, which can be shared with the healthcare provider for further review and investigation.

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The client is receiving a liter of 0.9% sodium chloride with potassium chloride (KCI) 30 mEq IV to infuse over 4 hours. Which nursing action has the highest priority for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has a continuous tube feeding develops a fever and reports experiencing dyspnea. Which action should the nurse implement?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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