A client with a history of congestive heart failure is prescribed daily oral furosemide. During morning rounds, the practical nurse gathers data before administering the medication. The electronic health record displays a morning serum potassium level of . The client's current vital signs are: blood pressure , heart rate , and respiratory rate . What is the priority action by the nurse?
- Withhold the furosemide and immediately report the clinical findings to the supervising registered nurse.Answer
- BAdminister the furosemide as prescribed and document the laboratory results in the client's chart.
- CInitiate an intravenous potassium replacement protocol before giving the diuretic.
- DGive the medication, as the borderline vital signs are typical compensatory mechanisms for heart failure.
Answer
The most appropriate action is to withhold the scheduled furosemide and report the critical potassium level and vital signs to the registered nurse.
Furosemide is a potent loop diuretic that causes the kidneys to excrete excess fluid along with essential electrolytes, particularly potassium. A serum potassium level of 2.8 mEq/L indicates significant hypokalemia (normal range is 3.5 to 5.0 mEq/L). Furthermore, the client's rapid heart rate (114 bpm) and low blood pressure (94/56 mmHg) are early clinical indicators of hypovolemia (fluid volume deficit). Administering the medication under these conditions could induce severe shock or fatal cardiac dysrhythmias. Therefore, the priority and safest action for a practical nurse is to withhold the dose and immediately notify the registered nurse or healthcare provider.
Step-by-Step Solution
Key Concept
Adverse effects of loop diuretics, recognition of hypokalemia and hypovolemia, and practical nurse scope of practice regarding medication safety.