Medical Surgical Potassium K+ #1

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. Reduce the maintenance fluid infusion
    • Rationale:

      This answer is not correct because changing the rate of the maintenance fluids requires a healthcare provider’s prescription; therefore, this action is outside of the scope of nursing practice and not appropriate.

  2. Encourage the client to increase fluid intake
    • Rationale:

      This answer is not correct because inadequate urine output is often indicative of poor renal function thus increasing the client’s oral fluid intake is not an appropriate action by the nurse.

  3. Notify the healthcare provider of the urine output and hold the dose
    • Rationale:

      This answer is correct because this client is experiencing inadequate urine output and administering the prescribed dose of potassium is not safe; therefore, the nurse notifies the health care provider regarding the client’s urine output and holds the dose of potassium.

  4. Obtain a serum potassium level and administer the dose if the level is low or normal
    • Rationale:

      This answer is not correct because a serum potassium level requires a healthcare provider’s prescription; therefore, this action is outside of the scope of nursing practice and not appropriate.

Overview

Potassium is a chemical that is critical to the function of muscle and nerve cells within the human body. Potassium is normally excreted from the body in the urine. Normal urine output is 30 mL/hr or 240 mL per 8 hours.

Explanation

Learning Outcomes

Potassium is normally excreted from the body in the urine. Normal urine output is 30 mL/hr or 240 mL per 8 hours. A client who has decreased urine output is at risk for hyperkalemia. Hyperkalemia can cause potentially life-threatening cardiac arrhythmias. Because this client is prescribed IV potassium and has inadequate urine output, it is not safe to administer the prescribed dose; therefore, the nurse must notify the healthcare provider of the urine output and hold the dose to decrease the likelihood of complications.

Test Taking Tip

Consider the consequences of poor urine output and administering the prescribed dose of potassium to answer this question correctly.

Video Rationale