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Difficulty: MediumReduction of Risk Potential

A practical nurse is caring for a client with heart failure who is receiving prescribed intravenous furosemide therapy. Which of the following assessment findings indicate a potential complication and require immediate escalation to the registered nurse? Select all that apply.

  1. A serum potassium level of 2.8 mEq/L2.8\text{ mEq/L} (2.8 mmol/L2.8\text{ mmol/L})Answer
  2. B
    Urine output of 850 mL850\text{ mL} over the past 4 hours4\text{ hours}
  3. New-onset premature ventricular contractions noted on the cardiac telemetry monitorAnswer
  4. A decrease in blood pressure from 142/86 mmHg142/86\text{ mmHg} to 88/52 mmHg88/52\text{ mmHg}Answer
  5. E
    A recorded weight loss of 1.5 kg1.5\text{ kg} (3.3 lb3.3\text{ lb}) since admission the previous day

Answer

The findings requiring immediate escalation are the critically low serum potassium level, the new-onset premature ventricular contractions, and the significant decrease in blood pressure.
Intravenous furosemide causes rapid fluid and electrolyte shifts. A serum potassium level of 2.8 mEq/L2.8\text{ mEq/L} indicates severe hypokalemia (normal range is 3.53.5 to 5.0 mEq/L5.0\text{ mEq/L}), placing the client at high risk for life-threatening dysrhythmias, such as the newly noted premature ventricular contractions. Furthermore, a significant drop in blood pressure to 88/52 mmHg88/52\text{ mmHg} indicates potential hypovolemia from excessive fluid loss. All three of these findings represent immediate safety risks that fall outside the practical nurse's scope to manage independently and require urgent escalation to the registered nurse.

Step-by-Step Solution

1
Analyze the prescribed medication and the client's underlying condition.
Furosemide is a potent loop diuretic used to treat fluid overload in heart failure by increasing the renal excretion of water, sodium, and potassium.
Understanding the mechanism of action is necessary to anticipate both the intended therapeutic effects and the potential adverse events.
2
Evaluate each assessment finding to determine if it is an expected outcome or a dangerous complication.
High urine output and moderate weight loss are expected therapeutic effects. Conversely, severe hypotension, significant hypokalemia, and new-onset dysrhythmias are adverse effects indicating systemic instability.
Distinguishing between expected physiological responses and abnormal, high-risk findings is the core of clinical judgment.
3
Determine the appropriate nursing action based on the practical nurse scope of practice.
The expected findings are documented and monitored. The adverse findings represent immediate safety risks that must be urgently reported to the registered nurse for medical intervention.
Timely escalation of critical changes reduces the risk potential and ensures the client receives appropriate, advanced care.

Key Concept

Monitoring for and escalating adverse effects of loop diuretics, specifically hypokalemia, hypotension, and cardiac dysrhythmias.
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Topics

Reduction of Risk Potential

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