The patient is prescribed to receive intravenous potassium chloride (KCL). Which actions should the nurse take when administering this medication? Select all that apply.
Add the ordered dose to the IV hanging.
Administer the dose IV push over 3 minutes.
Monitor the injection site for redness.
D. Use an infusion controller for the IV. E. Monitor fluid intake and output.
Correct Answer : C,D,E
The correct answer is choice C. Monitor the injection site for redness, D. Use an infusion controller for the IV, and E. Monitor fluid intake and output.
Choice A rationale:
Adding the ordered dose to the IV hanging is incorrect because potassium chloride should never be added to an already hanging IV solution due to the risk of uneven distribution and potential overdose.
Choice B rationale:
Administering the dose IV push over 3 minutes is incorrect because potassium chloride should never be given by direct IV injection. It must always be diluted and administered slowly to prevent cardiac complications.
Choice C rationale:
Monitoring the injection site for redness is correct because potassium chloride can cause irritation and phlebitis at the injection site.
Choice D rationale:
Using an infusion controller for the IV is correct because it ensures the potassium chloride is administered at a controlled rate, reducing the risk of rapid infusion and potential cardiac issues.
Choice E rationale:
Monitoring fluid intake and output is correct because it helps assess the patient’s overall fluid balance and detect any signs of fluid overload or deficit, which is crucial when administering potassium.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A, D, and E.
Choice A rationale:
Furosemide is a loop diuretic that promotes diuresis, causing an increase in urine output. It is essential for the patient to expect this effect and understand that it helps in reducing fluid overload.
Choice B rationale:
Feeling weak and dizzy is not an expected effect of furosemide. It is more commonly associated with dehydration or excessive fluid loss, which can occur if the medication causes too much diuresis.
Choice C rationale:
Taking furosemide before going to sleep is not recommended because it can lead to nighttime diuresis, disrupting sleep and potentially causing electrolyte imbalances.
Choice D rationale:
Swelling of the face or hands may indicate an adverse reaction to furosemide or an underlying medical issue. The nurse should instruct the patient to report any such symptoms promptly.
Choice E rationale:
Monitoring body weight daily is crucial for patients on diuretic therapy to assess fluid status and response to treatment. Rapid weight gain may indicate worsening fluid overload, while significant weight loss may indicate excessive diuresis.
Correct Answer is D
Explanation
The correct answer isd. Assess for indications of pulmonary embolism.
Choice A rationale:
Administering a sedative is not appropriate as the priority intervention. Sedatives can depress respiratory function, which is already compromised in this patient.
Choice B rationale:
Preparing for mechanical ventilation might be necessary if the patient’s condition worsens, but it is not the immediate priority. The priority is to identify the underlying cause of the symptoms.
Choice C rationale:
Massaging the calf area for tenderness is not relevant in this context. While calf tenderness can be a sign of deep vein thrombosis (DVT), which can lead to pulmonary embolism, the immediate priority is to assess for pulmonary embolism directly.
Choice D rationale:
Assessing for indications of pulmonary embolism is the priority because the patient’s symptoms (shortness of breath, chest pain, recent use of birth control pills, smoking history, and abnormal ABG values) strongly suggest a pulmonary embolism.Early identification and treatment are crucial to prevent further complications.
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