The patient is prescribed to receive intravenous potassium chloride (KCL). Which actions should the nurse take when administering this medication? Select all that apply.

Add the ordered dose to the IV hanging.

Administer the dose IV push over 3 minutes.

Monitor the injection site for redness.

D. Use an infusion controller for the IV. E. Monitor fluid intake and output.

Answer and Explanation

Correct Answer : C,D,E

The correct answer is choice C. Monitor the injection site for redness, D. Use an infusion controller for the IV, and E. Monitor fluid intake and output.

Choice A rationale:

Adding the ordered dose to the IV hanging is incorrect because potassium chloride should never be added to an already hanging IV solution due to the risk of uneven distribution and potential overdose.

Choice B rationale:

Administering the dose IV push over 3 minutes is incorrect because potassium chloride should never be given by direct IV injection. It must always be diluted and administered slowly to prevent cardiac complications.

Choice C rationale:

Monitoring the injection site for redness is correct because potassium chloride can cause irritation and phlebitis at the injection site.

Choice D rationale:

Using an infusion controller for the IV is correct because it ensures the potassium chloride is administered at a controlled rate, reducing the risk of rapid infusion and potential cardiac issues.

Choice E rationale:

Monitoring fluid intake and output is correct because it helps assess the patient’s overall fluid balance and detect any signs of fluid overload or deficit, which is crucial when administering potassium.

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Correct Answer is B

Explanation

Hypernatremia.

Choice A rationale:

Hypernatremia is the most likely condition the client is experiencing based on the laboratory result of Sodium 144 mEq/L, which is above the normal range of 136 to 145 mEq/L. Hypernatremia is an elevated sodium level in the blood and can cause various symptoms like extreme thirst, dry mucous membranes, and altered mental status.

Choice B rationale:

To address hypernatremia, the nurse should take two actions. Action 1: Prepare to check a serum albumin level. This is important as hypernatremia can be caused by a relative water deficit due to excess solutes, and measuring serum albumin helps assess the body's water balance. Action 2: Request a STAT ECG. Hypernatremia can lead to cardiac arrhythmias, so an ECG is essential to monitor the patient's heart rhythm. Parameters to Monitor: Parameter 1 - Serum bicarbonate level: Monitoring bicarbonate levels helps evaluate acid-base balance and assess the impact of hypernatremia on the body's buffering systems. Parameter 2 - Intake and Output: Monitoring the patient's fluid intake and output is crucial to ensure proper hydration and track response to treatment.

A. Dysrhythmias. B. Kussmaul respirations. C. Weakness. D. Cold, clammy skin.

Correct Answer is ["B","C","E"]

Explanation

Choice A rationale:

Dysrhythmias are not a direct consequence of diabetic ketoacidosis (DKA) or the acid-base imbalance indicated by the patient's pH of 7.2 and bicarbonate level of 20 mEq/L. DKA primarily affects the respiratory system, leading to Kussmaul respirations, not dysrhythmias.

Choice B rationale:

Kussmaul respirations are an expected finding in a patient with diabetic ketoacidosis (DKA) and metabolic acidosis. These deep, rapid breaths are the body's attempt to compensate for the acidosis by eliminating excess CO2.

Choice C rationale:

Weakness is a common symptom of DKA. The hyperglycemia and acidosis result in intracellular dehydration and impaired cellular function, leading to weakness and fatigue.

Choice D rationale:

Cold, clammy skin is not typically associated with DKA. Instead, patients with DKA may have warm, dry skin due to dehydration and impaired thermoregulation.

Choice E rationale:

Tachycardia is an expected finding in a patient with DKA. The metabolic acidosis and dehydration lead to an increase in heart rate as the body attempts to maintain perfusion.

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The patient is prescribed to receive intravenous potassium chloride (KCL). Which actions should the nurse take when administering this medication? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A patient newly diagnosed with diabetes mellitus is admitted to the emergency department with nausea, vomiting, and abdominal pain. ABG results reveal a pH of 7.2 and a bicarbonate level of 20 mEq/L. What other assessment findings should the nurse anticipate in this patient? Select all that apply.

Correct Answer is ["B","C","E"]

Explanation

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