A patient who is being treated for dehydration is receiving 5% dextrose and 0.45% normal saline with 20 mEq/L potassium chloride at a rate of 125 mL/hour
The nurse assuming care for the patient reviews the patient's serum electrolytes and notes a serum sodium level of 140 mEq/L and a serum potassium level of 3.6 mEq/L. The patient had a urine output of 250 mL during the last 12-hour shift. Which action will the nurse take?
a. Contact the patient's provider to discuss increasing the potassium chloride to 40 mEq/L.
b. Continue the intravenous fluids as ordered and reassess the patient frequently.
c. Notify the provider and discuss increasing the rate of fluids to 200 mL/hour.
d. Stop the intravenous fluids and notify the provider of the assessment findings.
ANS: D
The patient's potassium level is within normal limits, but the urine output is decreased, so the patient should not be receiving IV potassium. The nurse should stop the IV and report the findings to the provider. The patient does not need an increase in potassium. The patient needs more fluids but not with potassium.
You might also like to view...
Concerning anemia, nurses should be aware that:
1. it is the most common medical disorder of pregnancy. 2. it can trigger a reflex bradycardia. 3. the most common form of anemia is due to folate deficiency. 4. thalassemia is a European version of sickle cell anemia.
What is the most likely cause of this patient's low back pain?
A 33-year-old construction worker comes for evaluation and treatment of acute onset of low back pain. He notes that the pain is an aching located in the lumbosacral area. It has been present intermittently for several years; there is no known trauma or injury. He points to the left lower back. The pain does not radiate and there is no numbness or tingling in the legs or incontinence. He was moving furniture for a friend over the weekend. On physical examination, you note muscle spasm, with normal deep tendon reflexes and muscle strength. A) Herniated disc B) Compression fracture C) Mechanical low back pain D) Ankylosing spondylitis
The patient tells the nurse that her 12-year-old child asks to use her nail polish remover several times a day. When her friends come to visit, this seems to occur more frequently. What is the best response by the nurse?
1. "Your daughter may be 'huffing'; that is really scary." 2. "Your daughter may be 'huffing' or inhaling the remover." 3. "Your daughter may be 'huffing' or drinking small amounts of the remover." 4. "Your daughter may be 'huffing' or rubbing the remover on her skin."
A community identified cardiovascular disease as a priority need because the mortality rate is four times higher than the rate identified in Healthy People 2000. The approach to identifying this need was
a. Proactive b. Reactive c. Inactive d. Interactive