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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
- Myocardial infarction (MI) is suggested by chest pain radiating to the left arm, diaphoresis, shortness of breath, and epigastric discomfort. The pain described as "sharp, tight, and like indigestion" aligns with cardiac ischemia.
- Administering oxygen helps improve myocardial oxygenation, reducing ischemia.
- Aspirin 325 mg is a standard intervention in suspected MI to prevent further platelet aggregation and reduce the risk of worsening thrombosis in the coronary arteries.
- Monitoring vital signs is critical to assess for hemodynamic stability and signs of worsening cardiac function (e.g., hypotension, tachycardia).
- Monitoring ECG rhythm helps detect ST-elevation or other ischemic changes and assess for life-threatening arrhythmias.
- Morphine may be used for chest pain, but it is now considered secondary to nitroglycerin and beta-blockers.
- Verapamil is a calcium channel blocker used for rate control in arrhythmias but is not first-line for acute MI.
- Platelet count and WBC count are not immediately relevant to MI management.
- Serum glucose levels may be affected by stress but are not a primary concern in acute MI management.
Correct Answer is D
Explanation
A. NSTEMI (Non-ST Elevation Myocardial Infarction) does not present with ST-segment elevation on the ECG. Instead, it shows ST-segment depression or T-wave inversion and is diagnosed with elevated cardiac biomarkers.
B. Stable angina is predictable chest pain that occurs with exertion and is relieved by rest or nitroglycerin. It does not cause acute ECG changes.
C. Unstable angina is characterized by chest pain that occurs at rest or with minimal exertion and is not relieved by nitroglycerin. However, it does not show ST-segment elevation or myocardial infarction markers.
D. STEMI (ST-Elevation Myocardial Infarction) is diagnosed when there is ST-segment elevation in two or more contiguous ECG leads, indicating complete occlusion of a coronary artery and requiring immediate intervention such as percutaneous coronary intervention (PCI) or thrombolytic therapy.
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