A 2-month-old infant experiencing severe diarrhea is prescribed intravenous fluid replacement. Before adding potassium to this solution, which assessment should the nurse make?
A) Is voiding
B) Is sleeping
C) Is crying with tears
D) Hands are restrained
A
Feedback:
Although infants usually have a potassium depletion, potassium is not given until it is established the child is not in renal failure because giving potassium IV when the body has no outlet for excessive potassium can lead to excessively high potassium levels and heart block. Before this initial IV fluid is changed to a potassium solution, the nurse needs to be certain that the infant has voided, which is proof that the kidneys are functioning. The nurse does not need to ensure that the child is sleeping, crying with tears, or has the hands restrained.
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