A nurse is caring for a hospitalized child who is receiving a continuous infusion of intravenous (IV) potassium for the treatment of dehydration. The nurse monitors the child closely and noti-fies the physician if which of the following is noted?
1. Weight increase of 0.5 kg
2. Temperature of 100.8ยบ F rectally
3. Blood pressure (BP) unchanged from baseline
4. A decrease in urine output to 0.5 mL/kg/hr
4
Rationale: The priority assessment is to assess the status of urine output. Potassium should never be administered in the presence of oliguria or anuria. If urine output is less than 1 to 2 mL/kg/hr, potassium should not be administered. A slight elevation in temperature would be expected in a child with dehydration. A weight increase of 0.5 kg is relatively insignificant. A BP that is un-changed is a positive indicator unless the baseline was abnormal. However, there is no infor-mation in the question to support such data.
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