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 A

Explanation

Choice A rationale:

The client with a phosphate level of 5.7 mg/dL likely has a manifestation of hypoparathyroidism. Hypoparathyroidism leads to decreased parathyroid hormone (PTH) secretion, which causes increased renal phosphate reabsorption, leading to elevated phosphate levels in the blood.

Choice B rationale:

A calcium level of 9.8 mg/dL is within the normal range (8.5-10.2 mg/dL) and does not indicate hypoparathyroidism.

Choice C rationale:

A vitamin D level of 25 ng/mL is within the normal range (30-100 ng/mL) and does not suggest hypoparathyroidism.

Choice D rationale:

A magnesium level of 1.8 mEq/L is within the normal range (1.7-2.2 mEq/L) and does not directly indicate hypoparathyroidism.

A. Phosphorous. B. Magnesium. C. Potassium. D. Calcium.

Correct Answer is C

Explanation

Choice A rationale:

While acute renal failure can affect phosphorus levels, potassium is the electrolyte most commonly affected in this condition. Kidneys play a crucial role in regulating potassium levels in the body, and when they fail, potassium levels can become dangerously elevated.

Choice B rationale:

Acute renal failure can lead to alterations in magnesium levels, but potassium is typically more affected. Magnesium imbalances may occur but are not the primary concern in this condition.

Choice C rationale:

As mentioned earlier, potassium imbalances are common in acute renal failure. The nurse should closely monitor the patient's potassium levels and be prepared to intervene if they become too high or too low.

Choice D rationale:

Calcium levels may also be affected in acute renal failure, but potassium remains the most critical electrolyte to monitor in this condition.

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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

A nurse is reviewing the laboratory results for four clients. The nurse should recognize which of the following clients has a manifestation of hypoparathyroidism?

Correct Answer is A

Explanation

The nurse is admitting a patient who was diagnosed with acute renal failure. Which electrolyte should the nurse expect to be most affected with this disorder?

Correct Answer is C

Explanation

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