The client is receiving a liter of 0.9% sodium chloride with potassium chloride (KCI) 30 mEq IV to infuse over 4 hours. Which nursing action has the highest priority for this client?

Maintain continuous cardiac monitoring.

Monitor urinary output.

Check a serum potassium level postinfusion.

Obtain vital signs every 2 hours.

Answer and Explanation

The Correct Answer is A

A. Potassium affects the electrical activity of the heart, and abnormal potassium levels can lead to serious cardiac arrhythmias or other complications. Continuous cardiac monitoring is crucial when administering potassium chloride because it helps detect any arrhythmias or changes in heart function that might be caused by changes in potassium levels.
B. Monitoring urinary output is important because adequate urine output helps assess kidney function and ensures that potassium is being excreted properly. While monitoring urinary output is important, it is secondary to immediate cardiac monitoring during the infusion.
C. Checking the serum potassium level after the infusion is important to confirm that potassium levels have normalized or stayed within the target range. However, this action is not as immediate as continuous cardiac monitoring during the infusion.
D. Regular monitoring of vital signs is important to assess overall client stability and detect any systemic changes. However, obtaining vital signs every 2 hours might not be as critical as continuous cardiac monitoring when administering potassium.

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Correct Answer is A

Explanation

A. Encouraging the spouse to share their feelings is the most appropriate initial action. It provides an opportunity for the spouse to express their emotions and begin processing their grief. This approach validates the spouse’s feelings, offers emotional support, and establishes a supportive environment where the spouse can feel heard and understood.
B. Offering reassurance that the spouse is not alone can be comforting, but it may not fully address the immediate emotional needs of the spouse. It is important to first allow the spouse to express their feelings and then provide reassurance as part of the ongoing support.
C. Discussing alternative treatment options may be premature and could be perceived as dismissive of the spouse’s immediate emotional response. At this moment, the spouse is focused on the emotional impact of the terminal diagnosis rather than treatment options.
D. While offering hope can be part of supportive care, this approach might unintentionally minimize the spouse’s current feelings of loss and grief. It can also come across as dismissive of the immediate emotional impact of the diagnosis.

A. Determine which medications may be given in generic form rather than brand name only. B. Provide client teaching regarding the desired effects of the client's admission prescriptions. C. Reconcile prescribed medication dosages with the published recommended dosage ranges. D. Compare admission prescriptions with the list of medications previously taken by the client.

Correct Answer is D

Explanation

A. While determining if medications can be given in generic form can be a cost-effective measure and might be beneficial for the client, it is not the most urgent action to take during the admission process. The primary focus should be on ensuring that the medications are correct, safe, and appropriate for the client’s current condition and needs.
B. Client education about the desired effects of medications is important for ensuring the client understands their treatment and can identify any side effects or issues. However, this is typically done after ensuring that the medication list is accurate and reconciled. Teaching should be part of a comprehensive plan once the medication list and dosages are confirmed.
C. Reconciliation of prescribed medication dosages with recommended dosage ranges is important for ensuring the client receives appropriate and safe dosages. However, this action is part of a broader process of medication reconciliation, which involves verifying and comparing the current list of medications against previous records and established guidelines.
D. Comparing admission prescriptions with the list of medications previously taken by the client is a crucial first step in the medication reconciliation process. This action ensures that there is no duplication, omission, or incorrect change in the medication regimen. It helps prevent potential medication errors and ensures continuity of care.

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The client is receiving a liter of 0.9% sodium chloride with potassium chloride (KCI) 30 mEq IV to infuse over 4 hours. Which nursing action has the highest priority for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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