Question

52.   A nurse is preparing to administer digoxin orally to a client. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
A.   Obtain the client’s apical heart rate
B.   Remove the medication from the dispensing system
C.   Open the medication package
D.   Compare the client’s wristband to the medication administration record
E.   Document administration of the medication

1. A nurse is caring for a client who is to receive potassium replacement. The provider prescription reads “Potassium chloride 30 mEq in 0.9% sodium chloride 100mL over 30min. “For which of the following reasons should the nurse clarify this prescription with the provider?
a.   The potassium infusion rate is too rapid
b.   Potassium chloride solution be diluted in dextrose 5% in water
c.   The client should be treated by giving potassium by IV bolus
d.   Another formation of potassium should be given by IV

2.   A nurse is assessing a client's IV infusion site and notes that this site is cool and edematous. Which of the following actions should the nurse take?
a.   Slow the IV solution rate
b.   Apply a warm, moist compress
c.   Initiate a new IV distal to the initial site
d.   Maintain the extremity below the level of the heart.

Answer 1

52.

B.   Remove the medication from the dispensing system

D.   Compare the client’s wristband to the medication administration record

A.   Obtain the client’s apical heart rate

C.   Open the medication package

E.   Document administration of the medication

Explanation

First the nurse should collect the medication from dispensery. The prescribed medication should be correctly administered to the right client , so the client's wrist band should be checked along with medication administration record. The heart rate of client should be obtained prior to administration of digoxin. If heart rate is increased nurse should wait some time. Then open the medication package for administration of medication. Finally the nurse should document the procedure.

1.

a.   The potassium infusion rate is too rapid

Potassium chloride may be infused very cautiously at a rate up to 40 mEq/hour.The 24 hour total dose should not exceed 200 mEq.If it is injected too rapidly or in too high a dose, it may cause cardiac arrest within minutes.

2.

b.   Apply a warm, moist compress

First the nurse should administer a warm moist compress , then frequently observe for changes. If it is not getting decreased or getting hte condition worsened the nurse should initiate a new Iv site for infusion.