A nurse is caring for a client with severe hypokalemia. The provider places an order for IV potassium chloride (KCI) 60 mEq x1 now. Which action should the nurse take when caring for this client?
Discontinue cardiac monitoring during the infusion.
Administer KCI as a rapid IV bolus.
Only give the KCI via a central venous line.
Infuse the KCI at a rate of 10 mEq/hour.
The Correct Answer is C
A) Discontinue cardiac monitoring during the infusion:
Discontinuing cardiac monitoring during the infusion of potassium chloride is unsafe. Potassium infusions can significantly impact cardiac function, so continuous cardiac monitoring is necessary to detect any arrhythmias or other complications.
B) Administer KCI as a rapid IV bolus:
Administering potassium chloride as a rapid IV bolus is contraindicated due to the risk of severe adverse effects, including cardiac arrest. Potassium should be infused slowly to avoid complications.
C) Only give the KCI via a central venous line:
Potassium chloride is ideally administered through a central venous line because it is irritating to veins and can cause damage if given through a peripheral line. A central line reduces the risk of irritation and allows for safer infusion of potassium.
D) Infuse the KCI at a rate of 10 mEq/hour:
Infusing potassium chloride at a rate of 10 mEq/hour is generally too slow for an emergency situation requiring immediate correction of severe hypokalemia. For more urgent cases, higher rates may be required, but only under strict medical supervision to avoid complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Extreme thirst: While extreme thirst can be associated with electrolyte imbalances, particularly in conditions of dehydration or hypernatremia (elevated sodium levels), a sodium level of 116 mEq/L indicates hyponatremia (low sodium levels). Extreme thirst is less typical for hyponatremia.
B) Paresthesias: Paresthesias, or abnormal sensations like tingling or numbness, are more commonly associated with conditions of low calcium or potassium levels rather than sodium. In hyponatremia, neurological symptoms can occur, but they typically include lethargy or confusion rather than specific paresthesias.
C) Lethargy: Lethargy is a common symptom of severe hyponatremia. Low sodium levels can lead to cerebral edema and neurological disturbances, resulting in symptoms such as lethargy, confusion, and even seizures. This is a direct consequence of the altered osmotic balance affecting brain function.
D) Blood clots: Hyponatremia is not typically associated with an increased risk of blood clots. Blood clots are more related to conditions affecting coagulation factors, which are not directly influenced by sodium levels.
Correct Answer is D
Explanation
A) Chadwick's sign: Chadwick's sign is related to pregnancy and refers to the bluish discoloration of the cervix and vaginal walls due to increased blood flow. It is not associated with calcium levels or postoperative thyroidectomy.
B) Murphy's sign: Murphy's sign is used to diagnose gallbladder inflammation or cholecystitis. It involves palpation of the right upper quadrant of the abdomen and is not related to calcium levels or thyroid surgery.
C) Babinski's sign: Babinski's sign is a neurological reflex test used to assess the presence of upper motor neuron lesions. It is not associated with calcium levels or postoperative thyroidectomy.
D) Chvostek's sign: Chvostek's sign is a clinical indicator of hypocalcemia, where tapping on the facial nerve causes twitching of the facial muscles. With the client's calcium level of 3 mg/dL, which is significantly low, Chvostek's sign would likely be positive, indicating hypocalcemia.
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