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Difficulty: MediumPharmacological and Parenteral Therapies

A client in the intensive care unit is receiving a continuous intravenous (IV) infusion of sodium bicarbonate to treat severe metabolic acidosis. During the infusion, the nurse observes that the client has developed muscle cramping and a positive Trousseau's sign. The healthcare provider prescribes a dose of calcium gluconate via intravenous piggyback (IVPB). The client currently has a single-lumen peripherally inserted central catheter (PICC) in the right arm. Which of the following actions is the most appropriate for the nurse to take?

  1. Establish a new peripheral IV catheter in the opposite arm and administer the calcium gluconate through the new access.Answer
  2. B
    Attach the calcium gluconate as a secondary infusion to the lowest Y-site on the active sodium bicarbonate line.
  3. C
    Withhold the calcium gluconate and prepare to draw an arterial blood gas (ABG) sample because the symptoms indicate the acidosis is resolving.
  4. D
    Program the IV pump to infuse the calcium gluconate rapidly over 3 minutes to immediately reverse the tetany.

Answer

The nurse must establish a new peripheral IV catheter in the opposite arm and administer the calcium gluconate through the new access.
The correct action is to establish a new peripheral IV catheter. Sodium bicarbonate and calcium gluconate are highly incompatible. When mixed, they chemically react to form calcium carbonate, a solid precipitate that can cause fatal emboli. Because the client has a single-lumen PICC, a second venous access is required to safely administer the calcium without interrupting the critical bicarbonate infusion.

Step-by-Step Solution

1
Analyze the client's clinical symptoms and their relationship to the current intravenous therapy.
The client is exhibiting Trousseau's sign and muscle cramping, which are classic signs of acute hypocalcemia. This is a known complication of sodium bicarbonate administration, which increases blood pH (alkalosis) and causes calcium to bind tightly to albumin, lowering active ionized calcium levels.
Identifying the underlying physiological cause of the symptoms confirms the necessity and urgency of the calcium gluconate prescription.
2
Evaluate the compatibility of the continuous IV infusion with the newly prescribed piggyback medication.
Sodium bicarbonate and calcium gluconate are physically incompatible.
Mixing these two medications results in an immediate chemical reaction that forms calcium carbonate, a dangerous solid chalk-like precipitate.
3
Determine the safest method of administration given the client's current venous access.
The client only has a single-lumen PICC line. Administering both medications through this line would cause them to mix and precipitate.
Establishing a new peripheral IV access is required to safely administer the calcium gluconate without interrupting the critical continuous bicarbonate infusion or risking a fatal embolism from precipitation.

Key Concept

Intravenous medication compatibility and complications of acid-base correction
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Topics

Pharmacological and Parenteral Therapies

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