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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Hypocalcemia. Action to Take 1: Prepare to check a serum albumin level.
Rationale:
Hypocalcemia can be influenced by changes in serum albumin levels, as calcium may bind to albumin. Correcting calcium levels based on albumin can help determine the actual calcium status. Action to Take 2: Request a STAT ECG. Rationale: Hypocalcemia can lead to prolonged QT intervals on an electrocardiogram (ECG). A STAT ECG is necessary to assess cardiac function and detect any potential arrhythmias. Parameters to Monitor 1: Serum bicarbonate level. Rationale: Monitoring serum bicarbonate levels can help assess the client's acid-base balance and metabolic status. Abnormal bicarbonate levels may indicate metabolic disturbances. Parameters to Monitor 2: Intake and Output. Rationale: Monitoring intake and output is essential to evaluate the client's fluid balance and kidney function. Hypocalcemia can impact renal function, and assessing urine output is crucial.
Correct Answer is D
Explanation
Sodium 155 mEq/L. Choice A rationale:
A urine specific gravity of 1.035 indicates concentrated urine and is consistent with fluid volume deficit. However, it is not the most specific finding for this condition.
Choice B rationale:
A BUN (blood urea nitrogen) level of 19 mg/dL can be a normal value. It is within the reference range (usually around 7-20 mg/dL) and does not provide specific information about fluid volume deficit.
Choice C rationale:
A hematocrit of 44.9% can also be within the normal range for some individuals, and while it can be elevated in cases of fluid volume deficit, it is not as sensitive as other parameters for detecting this condition.
Choice D rationale:
This is the correct answer because a sodium level of 155 mEq/L is elevated and indicates hypernatremia, which is associated with fluid volume deficit. Hypernatremia occurs when there is a relative lack of water in relation to the sodium concentration in the blood, and it can lead to dehydration
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.