A nurse is caring for a client who is ordered Potassium 40 mEq IV. On hand is Potassium Chloride 20 mEq/mL. What is the nurse’s next action?

Mix potassium in 1 liter of normal saline.

Call the physician for order clarification.

Prepare 20 mEq of Potassium to give IV push.

Give the medication as ordered.

Answer and Explanation

The Correct Answer is B

A. While potassium is typically diluted in IV fluids, the concentration and infusion rate must be clarified before administration. A standard dilution is 10 mEq in 100 mL or 40 mEq in 1L, but this must be verified.
B. Calling the physician for clarification is the safest step. IV potassium should never be given undiluted or as an IV push due to the risk of fatal cardiac arrhythmias.
C. IV push potassium is never appropriate as it can cause cardiac arrest.
D. Administering the undiluted 20 mEq/mL solution is dangerous and requires proper dilution before administration.

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Correct Answer is D

Explanation

A. Muffled heart sounds are associated with pericardial effusion or tamponade, not infective endocarditis.
B. Palpitations can occur but are not a classic sign of infective endocarditis.
C. Hives suggest an allergic reaction, not endocarditis.
D. Splinter hemorrhages (tiny, red-brown streaks under the nails) are a classic sign of infective endocarditis due to small emboli from the infected heart valves.

A. Assess for acute pain B. Monitor fluid volume excess C. Prevention of falls D. Monitor heart rate and rhythm E. Assess for neurologic changes

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

Explanation

A. Assessing for acute pain is unnecessary. Sinus bradycardia is not typically associated with acute pain unless another condition, such as myocardial infarction, is present.
B. Monitoring fluid volume excess is incorrect. Sinus bradycardia is not directly related to fluid overload; however, fluid status may need to be monitored in clients with underlying cardiac conditions.
C. Prevention of falls is correct. Bradycardia can lead to dizziness, hypotension, and syncope, increasing the risk of falls.
D. Monitoring heart rate and rhythm is correct. Continuous monitoring is essential to detect any worsening bradycardia or associated arrhythmias.
E. Assessing for neurologic changes is correct. Bradycardia can reduce cerebral perfusion, leading to symptoms such as confusion, dizziness, or syncope.

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A nurse is caring for a client who is ordered Potassium 40 mEq IV. On hand is Potassium Chloride 20 mEq/mL. What is the nurse’s next action?

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Naxlex Comprehensive Predictor Exams

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Explanation

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