Potassium chloride intravenously is prescribed for a client with heart failure experiencing hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? Select all that apply.
1. Obtain an intravenous (IV) infusion pump
2. Monitor urine output duri...
potassium chloride intravenously is prescribed for a client with heart failure experiencing hypokalemia which actions should the nurse take to plan f
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Med Surg HESI Practice
Potassium chloride intravenously is prescribed for a client with heart failure
experiencing hypokalemia. Which actions should the nurse take to plan for preparation
and administration of the potassium? Select all that apply.
1. Obtain an intravenous (IV) infusion pump
2. Monitor urine output during administration
3. Prepare the med for bolus administration
4. Monitor the IV site for signs of infiltration or phlebitis
5. Ensure the med is diluted in the appropriate volume of fluid
6. Ensure that the bag is labeled so that it reads the volume of potassium in the solution
- Answer Answer: 1,2,4,5,6
*Rationale:* Potassium chloride administered intravenously must always be diluted in IV
fluid and infused via an infusion pump. Potassium chloride is never given by bolus (IV
push). Giving potassium chloride by IV push can result in cardiac arrest. The nurse
should ensure that the potassium is diluted in the appropriate amount of diluent or fluid.
The IV bag containing the potassium chloride should always be labeled with the volume
of potassium it contains. The IV site is monitored closely, because potassium chloride is
irritating to the veins and there is risk of phlebitis. In addition, the nurse should monitor
for infiltration. The nurse monitors urinary output during administration and contacts the
primary health care provider if the urinary output is less than 30 mL/hr.
The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and
a PaCO2 of 30 mm Hg (30 mm Hg). The nurse monitors the client for which clinical
manifestations associated with these ABG results? Select all that apply.
1. Nausea
2. Confusion
3. Bradypnea
4. Tachycardia
5. Hyperkalemia
6. Lightheadedness - Answer Answer: 1,2,4,6
*Rationale:* Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease
in hydrogen ion concentration that results from the accumulation of base or from a loss
of acid without a comparable loss of base in the body fluids. This occurs in conditions
that cause overstimulation of the respiratory system. Clinical manifestations of
respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia,
dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness
and tingling of the extremities. Hyperventilation (tachypnea) occurs. Bradypnea
describes respirations that are regular but abnormally slow. Hyperkalemia is associated
with acidosis
The nurse is administering 1 unit of packed red blood cells (PRBCs) to a client who has
never received a blood transfusion. The nurse suspects a transfusion reaction based on
clinical presentation. Based on this scenario, select the initial clinical findings for each
suspected condition. Choose one or more options.
3. Fluid overload
1. Back pain
2. Diff. breathing
3. Rash
4. Urticaria
5. Pruritus - Answer 1. Acute hemolytic reaction
-back pain
2. Allergic rxn
-rash
-urticaria
-pruritus
3. Fluid overload
-difficulty breathing
*Rationale:* There are different types of blood transfusion reactions, including fluid
volume overload, allergic reaction, and acute hemolytic reaction. In general, signs of an
immediate transfusion reaction include the following: chills and diaphoresis; muscle
aches, back pain, or chest pain; rash, hives, itching, and swelling; rapid, thready pulse;
dyspnea, cough, or wheezing; pallor and cyanosis; apprehension; tingling and
numbness; headache; and nausea, vomiting, abdominal cramping, and diarrhea. An
acute hemolytic reaction is usually characterized by back pain initially. An allergic
reaction is manifested by rash, urticaria, and pruritis as initial signs. Fluid volume
overload often is noted by difficulty breathing in the early phase.
Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5
mmol/L)?
1. The client with colitis
2. The client with Cushing's syndrome
3. The client who has been overusing laxatives
4. The client who has sustained a traumatic burn - Answer Answer: 4
*Rationale:* The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A
serum potassium level higher than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia.
, Clients who experience cellular shifting of potassium in the early stages of massive cell
destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are
at risk for hyperkalemia. The client with Cushing's syndrome or colitis and the client who
has been overusing laxatives are at risk for hypokalemia.
Contact precautions are initiated for a client with a health care-associated (nosocomial)
infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The nurse
prepares to provide colostomy care and should obtain which protective items to perform
this procedure?
1. Gloves and gown
2. Gloves and goggles
3. Gloves, gown and shoe protectors
4. Gloves, gown, goggles and mask or face shield - Answer Answer: 4
*Rationale:* Splashes of body secretions can occur when providing colostomy care.
Goggles and a mask or face shield are worn to protect the face and mucous
membranes of the eyes during interventions that may produce splashes of blood, body
fluids, secretions, or excretions. In addition, contact precautions require the use of
gloves, and a gown should be worn if direct client contact is anticipated. Shoe
protectors are not necessary.
The nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the
disorder, the nurse teaches the client about foods that are high in thiamine. The nurse
determines that the client has the best understanding of the dietary measures to follow if
the client states an intention to increase the intake of which food?
1. Milk
2. Chicken
3. Broccoli
4. Legumes - Answer Answer: 4
*Rationale:* The client with cirrhosis needs to consume foods high in thiamine.
Thiamine is present in a variety of foods of plant and animal origin. Legumes are
especially rich in this vitamin. Other good food sources include nuts, whole-grain
cereals, and pork. Milk contains vitamins A, D, and B2. Poultry contains niacin. Broccoli
contains vitamins C, E, and K and folic acid.
Several laboratory tests are prescribed for a client, and the nurse reviews the results of
the tests. Which laboratory test results should the nurse report? Select all that apply.
1. Platelets 35,000mm^3 (35 x 10^9/L)
2. Sodium 150 mEq/L (150mmol/L)
3. Potassium 5.0 mEq/L (5.0mmol/L)
4. Segmented neutrophils 40% (0.40)
5. Serum creatinine 1mg/dL (88.3 mcmol/L)
6. White blood cells 3000mm^3 (3.0 x 10^9/L) - Answer Answer: 1, 2, 4, 6
*Rationale:* The normal values include the following: platelets 150,000 to 400,000 mm3
(150 to 400 × 109/L); sodium 135 to 145 mEq/L (135 to 145 mmol/L); potassium 3.5 to
5.0 mEq/L (3.5 to 5.0 mmol/L); segmented neutrophils 62% to 68% (0.62 to 0.68);
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