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 C

Explanation

Step 1: 100 mL ÷ 30 min

Step 2: (100 mL ÷ 30 min) × 60 min/hr

Step 3: 3.33 mL/min × 60 min/hr

Answer: 200 mL/hr

A. Fever. B. Blood-tinged secretions. C. Tachypnea. D. IV infiltration.

Correct Answer is C

Explanation

The nurse’s priority for immediate intervention is tachypnea, which is rapid breathing.
Tachypnea can be a sign of respiratory distress and requires immediate intervention.
Choice A is wrong because while a fever may indicate an infection, it is not the priority for immediate intervention.
Choice B is wrong because while blood-tinged secretions may indicate bleeding, it is not the priority for immediate intervention.
Choice D is wrong because while IV infiltration may cause discomfort and require attention, it is not the priority for immediate intervention.

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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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