An older adult with a history of heart failure received a scheduled dose of an intravenous… — NCLEX-PN

An older adult with a history of heart failure received a scheduled dose of an intravenous loop diuretic at $0800$ . By $1000$ , the urinary catheter drainage bag contains $850\text{ mL}$ of clear yellow urine. The latest laboratory report indicates a serum potassium level of $3.1\text{ mEq/L}$ ( $3.1\text{ mmol/L}$ ). Current vital signs include a blood pressure of $102/58\text{ mm Hg}$ , a heart rate of $110\text{ beats per minute}$ , and respirations of $18\text{ per minute}$ . Based on these findings, which action should the practical nurse take first?

A
Document the copious urine output in the health record as a successful therapeutic response.
B
Administer a prescribed intravenous fluid bolus to address the client's decreasing blood pressure.
Report the physiological parameters and laboratory results to the supervising registered nurse.Answer
D
Instruct the client to consume potassium-rich foods from their breakfast tray.

Answer

Report the physiological parameters and laboratory results to the supervising registered nurse.

The client is exhibiting massive diuresis (

850\text{ mL}

in two hours), critical hypokalemia (

3.1\text{ mEq/L}

), and borderline vital signs (tachycardia) indicative of early hypovolemic shock. To reduce the risk of severe cardiac dysrhythmias or cardiovascular collapse, the practical nurse must immediately escalate these critical findings to the registered nurse so the provider can be notified and the care plan adjusted.

Step-by-Step Solution

Analyze the client's clinical data and laboratory results.

Identified a critically low potassium level (

3.1\text{ mEq/L}

) and signs of early hypovolemia (tachycardia, borderline hypotension, massive diuresis).

To evaluate the client's physiological response to the potent diuretic therapy.

Determine the risk potential and immediate clinical priorities.

Recognized that the client is at high risk for fatal cardiac dysrhythmias and hypovolemic shock.

Hypokalemia combined with rapid, excessive fluid depletion creates an unstable hemodynamic state.

Select the appropriate practical nursing intervention.

Escalate the critical findings to the registered nurse immediately.

Complex assessment, hemodynamic stabilization, and modification of the treatment plan fall outside the practical nurse scope of practice and require RN or provider intervention.

Key Concept

Reduction of Risk Potential: Complications of Diuretic Therapy

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