A nurse is administering potassium chloride via IV infusion to a client who has severe hypokalemia. Which of the following actions should the nurse take?

Check the infusion site at least every 4 hr.

Start the infusion at 30 mEq/hr.

Assess the client for a positive Chvostek sign.

Monitor the client for adequate urine output.

Answer and Explanation

The Correct Answer is D

Monitor the client for adequate urine output.
When administering potassium chloride via IV infusion to a client who has severe hypokalemia, it is important for the nurse to monitor the client’s urine output to ensure that their kidneys are functioning properly and that they are able to excrete excess potassium.
Choice A is incorrect because the infusion site should be checked more frequently than every 4 hours.
Choice B is incorrect because the maximum recommended rate of infusion for potassium chloride is 10 mEq/hr.
Choice C is incorrect because Chvostek’s sign is used to assess for hypocalcemia, not hypokalemia.

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Correct Answer is B

Explanation

The correct answer is: b. “I apply a lubricating lotion to the cracked areas on the soles of my feet every morning.”

Choice A reason: Elevating the feet for long periods is not generally recommended for clients with Peripheral Arterial Disease (PAD). This is because elevation can decrease arterial blood flow to the feet, which is already compromised in PAD. The goal is to promote blood flow to the extremities, and elevation might work against this, especially if done for extended periods.

Choice B reason: Applying a lubricating lotion to the feet, particularly on the soles where the skin can become very dry and cracked, is beneficial for someone with PAD. It helps to maintain skin integrity and prevent skin breakdown, which can lead to serious complications due to the reduced blood flow and healing capacity in PAD.

Choice C reason: Soaking the feet in hot water is not advisable for individuals with PAD. They may have reduced sensation in their feet due to poor circulation, which increases the risk of burns from hot water. Additionally, prolonged soaking can lead to maceration of the skin, making it more susceptible to injury and infection.

Choice D reason: Using a heating pad, even on a low setting, to keep the feet warm is risky for clients with PAD. Due to decreased sensation from poor circulation, there is a danger of burns because the client may not feel how hot the heating pad is. It’s better to wear warm socks or use room temperature control to keep the feet warm.

A. Implement airborne precautions. B. Determine the client's blood type. C. Institute bleeding precautions. D. Avoid administering IV pain medication.

Correct Answer is C

Explanation

The nurse should institute bleeding precautions for the client.

Petechiae are small red or purple spots on the skin caused by broken capillaries, which can be a sign of low platelet count (thrombocytopenia) and an increased risk of bleeding.
Bleeding precautions include measures such as using a soft-bristled toothbrush, avoiding injections, and avoiding activities that could result in injury.
Choice A is incorrect because airborne precautions are used to prevent the spread of infectious diseases that are transmitted through the air, and are not necessary in this situation.
Choice B is incorrect because determining the client’s blood type is not necessary in this situation.
Choice D is incorrect because avoiding IV pain medication is not necessary in this situation; however, the nurse should monitor the client for signs of bleeding and bruising.

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A nurse is administering potassium chloride via IV infusion to a client who has severe hypokalemia. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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