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Difficulty: Very hardPharmacological Therapies

An older adult client with a history of chronic obstructive pulmonary disease (COPD) and heart failure is receiving a continuous intravenous infusion of 0.9% sodium chloride. The practical nurse is preparing to administer scheduled morning medications, which include oral levofloxacin, oral furosemide, and subcutaneous enoxaparin. During the pre-administration assessment, the client appears restless. Vital signs are: heart rate 112 beats/min, blood pressure 90/58 mm Hg, and oxygen saturation 88% on 2 L/min via nasal cannula. The morning laboratory report shows a platelet count of 95,000/mm³ (95×10995 \times 10^9/L). Based on these findings, which action should the practical nurse take first?

  1. A
    Administer the levofloxacin and furosemide, withhold the enoxaparin due to the platelet count, and recheck the blood pressure in one hour.
  2. B
    Increase the supplemental oxygen to 4 L/min to address the hypoxia, administer the furosemide, and document the client's restlessness.
  3. Withhold all scheduled medications and immediately notify the registered nurse of the client's vital signs and laboratory results.Answer
  4. D
    Administer the medications rapidly due to the client's declining status, bypassing the standard barcode scanning procedure to expedite care.

Answer

The correct action is to withhold all scheduled medications and immediately notify the registered nurse of the assessment findings and laboratory results.
The client is experiencing acute clinical deterioration evidenced by restlessness, tachycardia, hypotension, and hypoxia, alongside a critical laboratory finding (thrombocytopenia). Administering furosemide will exacerbate the hypotension, and enoxaparin poses a severe bleeding risk due to the low platelets. The practical nurse must recognize this complex, unstable presentation, withhold the potentially dangerous pharmacological therapies, and immediately report the findings to the registered nurse for urgent collaborative intervention.

Step-by-Step Solution

1
Analyze the client's vital signs and clinical presentation.
The client is restless with tachycardia (112 beats/min), borderline hypotension (90/58 mm Hg), and hypoxia (88%), indicating acute hemodynamic and respiratory deterioration.
Recognizing signs of acute decline is the first step in determining if scheduled medications are safe to administer.
2
Evaluate the laboratory results against the prescribed medications.
The platelet count of 95,000/mm³ indicates thrombocytopenia. Enoxaparin is an anticoagulant and is contraindicated when platelet counts are critically low due to severe bleeding risk.
Medications must be correlated with current diagnostic data to prevent adverse drug events.
3
Synthesize data to determine the safety of the remaining medications.
Furosemide is a loop diuretic that decreases fluid volume. Administering it to a client with a blood pressure of 90/58 mm Hg will worsen the hypotension and decrease perfusion further.
Pharmacological principles dictate holding medications that will exacerbate abnormal physiological parameters.
4
Select the appropriate nursing intervention within the practical nursing scope of practice.
The nurse must withhold all medications and escalate the situation immediately to the registered nurse or primary healthcare provider for urgent medical intervention.
The practical nurse must recognize when a client's condition exceeds the stability required for routine medication administration and requires higher-level clinical judgment.

Key Concept

Pre-administration Assessment and Safe Scope of Practice
Estimated Time:2m 0s
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Topics

Pharmacological Therapies

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