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Difficulty: MediumPharmacological Therapies

A client with heart failure is prescribed a scheduled dose of oral furosemide. During the morning data collection, the practical nurse notes that the client's serum potassium level is 2.9 mEq/L2.9\text{ mEq/L}. The client's vital signs include a heart rate of 108 beats/min108\text{ beats/min} and a blood pressure of 96/58 mmHg96/58\text{ mmHg}. Which action is the priority for the nurse?

  1. Withhold the furosemide and immediately report the findings to the supervising registered nurse.Answer
  2. B
    Administer the furosemide because mild tachycardia and slight hypotension are expected in heart failure.
  3. C
    Document the potassium level in the chart and proceed with the scheduled medication administration.
  4. D
    Prepare to administer a dose of potassium chloride via intravenous push to quickly correct the deficit.

Answer

The priority action is to withhold the scheduled furosemide and immediately report the vital signs and laboratory results to the registered nurse.
The correct action is to withhold the furosemide and notify the registered nurse. The client's potassium level of 2.9 mEq/L indicates severe hypokalemia. Since furosemide is a potassium-depleting loop diuretic, administering the dose would worsen the hypokalemia, placing the client at high risk for lethal cardiac dysrhythmias. Furthermore, the client's borderline vital signs (tachycardia and hypotension) suggest clinical deterioration that must be escalated.

Step-by-Step Solution

1
Analyze the laboratory results.
The serum potassium level is 2.9 mEq/L, which indicates critical hypokalemia (normal range: 3.5 to 5.0 mEq/L).
Identifying abnormal laboratory values is essential before administering medications that affect those values.
2
Evaluate the medication's mechanism of action.
Furosemide is a potassium-wasting loop diuretic. Administering it will further lower the client's potassium level.
Understanding drug classifications helps predict adverse effects and prevents medication errors.
3
Determine the appropriate nursing intervention based on scope of practice.
The nurse must withhold the medication to prevent harm and notify the registered nurse or provider.
Practical nurses must escalate critical findings and withhold medications when administration poses a direct safety risk.

Key Concept

Pre-administration safety checks and recognizing critical laboratory values associated with pharmacological therapies.
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Topics

Pharmacological Therapies

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