A laboratory technician urgently reports that a client's serum potassium level is 2.6 \tex… — NCLEX-RN

A laboratory technician urgently reports that a client's serum potassium level is $2.6 \text{ mEq/L}$ . The healthcare provider immediately prescribes an intravenous (IV) infusion of $40 \text{ mEq}$ of potassium chloride in $100 \text{ mL}$ of 0.9% sodium chloride to be infused over 30 minutes. Which of the following is the priority nursing action before administering this medication?

Withhold the medication and immediately contact the healthcare provider to clarify the unsafe infusion rate.Cevap
B
Program the infusion pump to deliver $40 \text{ mL/hr}$ to ensure the medication is administered at a slow, controlled pace.
C
Connect the secondary tubing to the Y-site of the client's continuous intravenous fluids without verifying compatibility to expedite treatment.
D
Instruct the unlicensed assistive personnel to perform a baseline assessment of the client's peripheral intravenous insertion site.

Cevap

The nurse's priority action is to withhold the medication and immediately contact the healthcare provider to clarify the unsafe infusion rate.

The prescribed administration rate of 40 mEq of potassium chloride over 30 minutes (equivalent to 80 mEq/hr) is dangerously high and can cause fatal cardiac arrhythmias. The maximum safe infusion rate for intravenous potassium chloride is generally 10 mEq/hr for a peripheral line and up to 20 mEq/hr for a central line with continuous cardiac monitoring. The nurse's priority is to identify this life-threatening safety violation and contact the prescribing provider to clarify the order.

Adım Adım Çözüm

Analyze the prescribed dosage and rate of the intravenous potassium chloride.

The prescription calls for

40 \text{ mEq}

to be infused over 30 minutes, which equates to an hourly rate of

80 \text{ mEq/hr}

Verifying the prescription against clinical safety parameters is the first critical step in medication administration.

Compare the calculated rate against maximum safe administration guidelines.

The prescribed rate of

80 \text{ mEq/hr}

vastly exceeds the absolute maximum safe limit of

10

20 \text{ mEq/hr}

Infusing potassium chloride too rapidly can induce severe hyperkalemia and lethal cardiac dysrhythmias, such as ventricular fibrillation.

Determine the priority nursing intervention based on the safety analysis.

The nurse must withhold the medication and contact the healthcare provider immediately to correct the prescription.

Nurses are legally and ethically responsible for ensuring medication safety and must actively question and halt orders that are demonstrably harmful.

Anahtar Kavram

Safe administration of high-alert intravenous medications (Potassium Chloride)

Tahmini Süre:1m 30s

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