A nurse is caring for a client who is to receive potassium replacement. The provider’s prescription reads, “Potassium chloride 30 mEq in 0.9% sodium chloride 100 mL IV over 30 min.” For which of the following reasons should the nurse clarify this prescription with the provider?

The potassium infusion rate is too rapid.

Another formulation of potassium should be given IV.

Potassium chloride should be diluted in dextrose 5% in water.

The client should be treated by giving potassium by IV bolus.

Answer and Explanation

The Correct Answer is A

According to various guidelines12345, the recommended rate of intravenous potassium replacement is 10-20 mEq/h with continuous ECG monitoring. The maximum rate is 40 mEq/h in emergency situations. The prescription given by the provider exceeds this limit and could cause cardiac arrhythmias or hyperkalemia.

Choice B is wrong because potassium chloride is a common and appropriate formulation of potassium for intravenous administration.

Choice C is wrong because potassium chloride should not be diluted in dextrose 5% in water, as this could cause hyperglycemia or osmotic diuresis.

Choice D is wrong because potassium should never be given by IV bolus, as this could cause cardiac arrest or tissue necrosis.

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Correct Answer is B

Explanation

Choice A rationale:

The air bubble should not be expelled from the syringe before administering enoxaparin. The air bubble is included to ensure that the entire dose is administered and to help prevent leakage of the medication into the subcutaneous tissue, which can reduce bruising.

Choice B rationale:

After administering enoxaparin, applying firm pressure (but not massaging) to the injection site helps minimize bruising and bleeding. It's important not to massage the site as this can increase the risk of bleeding.

Choice C rationale:

The needle should be inserted fully into the subcutaneous tissue at a 90-degree angle (or at a 45-degree angle if the client has little subcutaneous tissue). Inserting the needle halfway may result in improper administration.

Choice D rationale:

Enoxaparin is a low-molecular-weight heparin that should be administered subcutaneously, not intramuscularly. Administering it intramuscularly could increase the risk of bleeding and is not the appropriate route for this medication.

A. Oliguria. B. Nausea. C. Headaches. D. Weight gain.

Correct Answer is A

Explanation

Osmotic laxatives work by drawing water into the colon to soften the stool and stimulate bowel movements. However, excessive use of osmotic laxatives can cause fluid volume deficit, which is a state of reduced intravascular volume.

One of the signs of fluid volume deficit is oliguria, which means low urine output.

Choice B. Nausea is wrong because nausea is a common side effect of osmotic laxatives, not an indication of fluid volume deficit.

Choice C. Headaches is wrong because headaches are more likely to be caused by dehydration, which is a state of reduced total body water, mostly affecting the intracellular fluid compartment.

Dehydration can result from osmotic laxatives, but it is not the same as fluid volume deficit.

Choice D. Weight gain is wrong because weight gain is not a sign of fluid volume deficit.

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A nurse is caring for a client who is to receive potassium replacement. The provider’s prescription reads, “Potassium chloride 30 mEq in 0.9% sodium chloride 100 mL IV over 30 min.” For which of the following reasons should the nurse clarify this prescription with the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is assessing a client who is taking an osmotic laxative. Which of the following findings should the nurse identify as an indication of fluid volume deficit?

Correct Answer is A

Explanation

A nurse is assessing a client who is receiving heparin via continuous IV. The client has an aPTT of 90 seconds. The nurse should monitor the client for which of the following changes in their vital signs?

A nurse is preparing to administer amphotericin B lipid complex via intermittent IV bolus to a client who has infective endocarditis. Which of the following actions should the nurse take?

A nurse is mixing regular insulin and NPH insulin in the same syringe prior to administering it to a client who has diabetes mellitus. Which of the following actions should the nurse take first?

A nurse is receiving a medication prescription by telephone from a provider. The provider states, “Administer 6 milligrams of morphine IV push every 3 hours as needed for acute pain.” How should the nurse transcribe the prescription in the client’s medical record?

A nurse is caring for a client who is to receive potassium replacement. The provider’s prescription reads, “Potassium chloride 30 mEq in 0.9% sodium chloride 100 mL IV over 30 min.” For which of the following reasons should the nurse clarify this prescription with the provider?

A nurse is assessing a client’s IV infusion site and notes that the site is cool and edematous. Which of the following actions should the nurse take?

A nurse is preparing to administer subcutaneous heparin to a client. Which of the following actions should the nurse take?

A nurse is assessing a client who is receiving intravenous therapy. The nurse should identify which of the following findings as a manifestation of fluid volume excess?