Electrolytes Question #24

Question

A client is receiving intravenous potassium supplementation in addition to maintenance fluids. The urine output has been 120 mL every 8 hours for the past 16 hours and the next dose of potassium is due. Before administering the potassium, which action should the nurse take?

Answers

  1. Encourage the client to increase fluid intake
    • Rationale:
  2. Reduce the maintenance fluid infusion
    • Rationale:
  3. Obtain a serum potassium level and administer the dose if the level is low or normal
    • Rationale:
  4. Notify the healthcare provider of the urine output and hold the dose
    • Rationale:

Overview

Explanation

The correct answer is D. Urine output is an indication of renal function. Normal urine output is at least 30 ml/hour. Clients with impaired renal function are at risk for hyperkalemia. Drawing blood for a potassium level and changing the rate of the maintenance fluids require a healthcare provider’s order. Increasing oral fluids could exacerbate renal failure.

NCLEX TIP: Using critical thinking is recommended when reading priority questions. Recognizing key words in the answer choices will allow you to know how to choose the correct answer for the question. Go through each answer choice and decide is it: Maslow’s hierarchy, safety-related, or following the nursing process (ADPIE). Never complete a nursing action that is outside the scope of practice.

Learning Outcomes

Test Taking Tip

Video Rationale