A nurse is preparing to administer potassium chloride to a client who has a potassium level of 5.8 mEq/L. Which of the following actions should the nurse take?
Hold the medication until the client has his evening meal.
Inform the provider of the client's potassium level.
Obtain a prescription to increase the dosage of the medication.
Give the medication as prescribed.
The Correct Answer is B
A. Hold the medication until the client has his evening meal: Holding the medication for this reason is inappropriate because the issue is the elevated potassium level, not the timing with meals.
B. Inform the provider of the client's potassium level: Correct. A potassium level of 5.8 mEq/L is elevated (hyperkalemia), and the provider should be informed immediately before administering any more potassium.
C. Obtain a prescription to increase the dosage of the medication: Increasing the dosage would be dangerous given the elevated potassium level.
D. Give the medication as prescribed: Administering potassium chloride with a high potassium level is unsafe and could exacerbate the hyperkalemia.
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Related Questions
Correct Answer is B
Explanation
A. Hold the medication until the client has his evening meal: Holding the medication for this reason is inappropriate because the issue is the elevated potassium level, not the timing with meals.
B. Inform the provider of the client's potassium level: Correct. A potassium level of 5.8 mEq/L is elevated (hyperkalemia), and the provider should be informed immediately before administering any more potassium.
C. Obtain a prescription to increase the dosage of the medication: Increasing the dosage would be dangerous given the elevated potassium level.
D. Give the medication as prescribed: Administering potassium chloride with a high potassium level is unsafe and could exacerbate the hyperkalemia.
Correct Answer is D
Explanation
A. Allow the client to expel some fluid before continuing: This action may provide some relief but can disrupt the enema procedure and is not the most effective immediate response.
B. Encourage the client to bear down: Bearing down could increase discomfort and does not address the cause of the cramping.
C. Stop the enema and document that the client did not tolerate the procedure: This is not necessary unless the discomfort is severe. First, less invasive measures should be tried to relieve the discomfort.
D. Lower the height of the solution container: Lowering the height of the enema container reduces the flow rate of the solution, which can alleviate cramping and discomfort.
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