HESI PN Module Exam 10

HESI PN Module Exam 10 A health care provider writes a prescription for the administration of intravenous (IV) potassium chloride to a client with hypokalemia. The nurse should reinforce which client instructions? A) A catheter will be inserted to drain your bladder B) A large intravenous line will be inserted into your chest vein C) This infusion requires use of a large caliber IV tubing D) This medication is diluted in a large bag of IV fluid and infused slowly into your vein - CORRECT ANSWER D) The medication is diluted in a large bag of IV fluid and infused slowly into your vein Rationale: Potassium chloride administered IV must always be diluted in IV fluid. Undiluted potassium chloride given IV can cause cardiac arrest. Potassium chloride is never administered as a bolus (IV push) injection; an IV push would result in sudden severe hyperkalemia, which could precipitate cardiac arrest. Although urine output is monitored carefully during administration, it is not necessary to insert a Foley catheter unless this is specifically prescribed. Potassium chloride should be administered with the use of a controlled IV infusion device to avoid bolus infusion and increased risk of cardiac arrest. A central IV line is not necessary; potassium chloride may be administered through a peripheral IV line. A nurse notes that a client's serum potassium level is 5.8 mEq/L. The nurse interprets this as an expected finding in the client with? A) Diarrhea B) Wound drainage C) Addison disease D) Heart failure being treated with loop diuretics - CORRECT ANSWER C) Addison disease Rationale: A serum potassium level greater than 5.1 mEq/L indicates hyperkalemia, and the nurse would report the finding to the health care provider. Adrenal insufficiency (Addison disease) is a cause of hyperkalemia. Other common causes of hyperkalemia include tissue damage, such as that in burn injuries, renal failure, and the use of potassium-sparing diuretics. The client with diarrhea or wound drainage or the client being treated with diuretics is at risk for hypokalemia. A nurse is caring for a client experiencing hyponatremia who was admitted to the medical-surgical unit with fluid-volume overload. For which clinical manifestations of this electrolyte imbalance does the nurse monitor this client? Select all that apply. A) Slow pulse B) Decreased urine output C) Skeletal muscle weakness D) Hyperactive bowel sounds E) Hyperactive deep tendon reflexes - CORRECT ANSWER C, D