During morning rounds on a medical-surgical unit, a client with heart failure is due for a… — NCLEX-PN

During morning rounds on a medical-surgical unit, a client with heart failure is due for a scheduled oral dose of spironolactone. The electronic health record indicates the client's morning serum potassium level is $6.1\text{ mEq/L}$ . What is the most appropriate action for the practical nurse to take?

Withhold the spironolactone and promptly report the laboratory finding to the registered nurse.Answer
B
Administer the medication, as this laboratory value represents an expected finding for a client taking a diuretic.
C
Verify the client's identity using two identifiers and administer the medication as prescribed.
D
Assess the client's blood pressure and administer the dose if the systolic reading is greater than $90\text{ mm Hg}$ .

Answer

The practical nurse should withhold the spironolactone and immediately report the elevated potassium level to the registered nurse.

Spironolactone is a potassium-sparing diuretic. A normal serum potassium level ranges from

3.5

5.0\text{ mEq/L}

. A level of

6.1\text{ mEq/L}

indicates severe hyperkalemia, which can lead to life-threatening cardiac dysrhythmias. Therefore, the safest and most appropriate action within the PN scope of practice is to withhold the medication and notify the RN immediately.

Step-by-Step Solution

Analyze the client's laboratory data against normal reference ranges.

The serum potassium level is

6.1\text{ mEq/L}

, which is significantly above the normal range of

3.5

5.0\text{ mEq/L}

Identifying normal versus abnormal laboratory values is a critical safety step before medication administration.

Correlate the laboratory finding with the prescribed medication's mechanism of action.

Spironolactone is recognized as a potassium-sparing diuretic.

Understanding pharmacodynamics reveals that administering this drug will further elevate the already critical potassium level.

Determine the appropriate clinical action within the practical nursing scope of practice.

The medication must be withheld and the critical finding escalated to the supervising registered nurse.

The PN must ensure client safety by preventing the administration of a contraindicated drug and communicating critical data promptly.

Key Concept

Medication Safety: Recognizing contraindications and escalating critical laboratory values

Estimated Time:1m 0s

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