# Situation: A 49-year-old woman who had most of her small bowel removed 6 months ago is admitted after 2 weeks of very poor intake. She weighs 38 kg (body mass index 15 kg/m²) and reports tingling around her mouth and in her fingertips. Her serum total calcium is 7.1 mg/dL (1.77 mmol/L) (8.6–10.2 mg/dL; 2.15–2.55 mmol/L), and her serum albumin is 3.9 g/dL (39 g/L). A sodium bicarbonate infusion is running through her only intravenous (IV) catheter. The physician orders calcium gluconate 1 g IV over 10 minutes. What should the nurse do?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629704  
> language: ko  
> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 49-year-old woman who had most of her small bowel removed 6 months ago is admitted after 2 weeks of very poor intake. She weighs 38 kg (body mass index 15 kg/m²) and reports tingling around her mouth and in her fingertips. Her serum total calcium is 7.1 mg/dL (1.77 mmol/L) (8.6–10.2 mg/dL; 2.15–2.55 mmol/L), and her serum albumin is 3.9 g/dL (39 g/L).

A sodium bicarbonate infusion is running through her only intravenous (IV) catheter. The physician orders calcium gluconate 1 g IV over 10 minutes. What should the nurse do?

## 보기

1. Give it by deep intramuscular injection instead
2. Give it IV push over 1 minute to stop the tingling
3. Inject it into the port nearest the catheter hub
4. Insert a second IV catheter for the calcium **✔ 정답**

**정답: 4**

## 해설

Calcium must never be mixed with sodium bicarbonate or phosphate in the same line because they form a precipitate. The calcium gluconate therefore needs its own IV access and is given slowly, over about 5–10 minutes, with ECG monitoring. Rapid injection can cause bradycardia, hypotension, and dysrhythmias.

## 심화 해설

The safe action
This client has symptomatic hypocalcemia: tingling around the mouth and in the fingertips, with a total calcium of 7.1 mg/dL (1.77 mmol/L) and a normal albumin of 3.9 g/dL, so the low value is real and not explained by low protein. The physician orders calcium gluconate 1 g IV over 10 minutes. Her only IV catheter is running a sodium bicarbonate infusion. Calcium must never be mixed with sodium bicarbonate or phosphate in the same line, because they react to form an insoluble precipitate. The nurse inserts a second IV catheter so the calcium can be given through its own access.

Why the precipitate is dangerous
Calcium combines with bicarbonate to form calcium carbonate, and with phosphate to form calcium phosphate. These solids can block the catheter, and if particles enter the bloodstream they can lodge in small vessels such as those in the lungs. The drug also loses its effect. Flushing the line between drugs is not a reliable substitute when a bicarbonate infusion is running continuously in the same catheter, so a separate line is the safe choice.

How calcium gluconate is given
IV calcium is given slowly, over about 5 to 10 minutes, with ECG monitoring. Rapid injection can cause bradycardia, hypotension, and dysrhythmias. The nurse checks the IV site carefully, because calcium solutions irritate tissue and extravasation can cause tissue injury and necrosis. The client is assessed for improvement in symptoms and for signs such as Chvostek's and Trousseau's signs, and serum calcium is rechecked.

Why the other options are wrong

| Option | Problem |
| --- | --- |
| Deep intramuscular injection | Calcium salts irritate tissue and can cause necrosis; the order is for slow IV |
| IV push over 1 minute | Too fast; risks bradycardia, hypotension, and dysrhythmias |
| Port nearest the catheter hub | Still mixes with bicarbonate in the same line and precipitates |
| Second IV catheter | Keeps calcium away from bicarbonate |

Watch out! Injecting into the port nearest the hub may seem to minimize contact with the bicarbonate, but the two solutions still meet inside the catheter. Short contact is enough to form a precipitate. Her history of extensive small bowel removal and poor intake explains her deficiency, and she may also be low in magnesium, which the team should check because low magnesium makes hypocalcemia harder to correct.

Exam takeaway
Never give IV calcium in the same line as sodium bicarbonate or phosphate; give it slowly with ECG monitoring through its own access. Key point! When an item mentions a running infusion and a new IV drug, always check for compatibility before choosing a route.

## 임상 시나리오

IV Calcium With a Bicarbonate InfusionSymptomatic hypocalcemia after small bowel resection
Calcium precipitates with sodium bicarbonate or phosphate. Give calcium gluconate through a separate IV line.

Infuse slowly over about 5 to 10 minutes with ECG monitoring, and watch the site for extravasation.

Reassess tingling, Chvostek's and Trousseau's signs, serum calcium, and magnesium.

CautionDo not inject calcium into the bicarbonate line at any port, and never give it as a rapid IV push.

## 핵심 개념

- **Hypocalcemia** — A low serum calcium causing tingling, muscle cramps, tetany, and dysrhythmias.
- **Calcium gluconate** — An IV calcium salt used to treat hypocalcemia, given slowly with ECG monitoring.
- **Precipitate** — An insoluble solid formed when incompatible solutions are mixed.
- **Drug incompatibility** — A physical or chemical reaction between drugs that makes them unsafe to give together.
- **Extravasation** — Leakage of an IV solution into surrounding tissue, which can cause injury.

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