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Difficulty: MediumReduction of Risk Potential

Following an admission for severe heart failure exacerbation, a client is prescribed scheduled doses of furosemide. Which of the following nursing actions must the practical nurse implement to minimize the client's risk of physiological complications? (Select all that apply.)

  1. Verify the client's identity by asking them to state their name and date of birth prior to giving the medicationAnswer
  2. Obtain the client's daily weight using the same scale at the same time each morningAnswer
  3. Withhold the diuretic and notify the registered nurse if the client exhibits new-onset resting tachycardiaAnswer
  4. D
    Administer the furosemide via direct intravenous push to ensure rapid therapeutic diuresis
  5. E
    Delay reporting a morning serum potassium level of 2.8 mEq/L (2.8 mmol/L) until the provider's afternoon rounds
  6. F
    Proceed with the scheduled dose if the client's blood pressure decreases to 88/54 mmHg without further evaluation

Answer

The correct actions include verifying the client's identity prior to medication administration, obtaining daily weights using consistent methods, and withholding the medication while notifying the registered nurse if the client exhibits new-onset resting tachycardia.
The correct actions demonstrate safe clinical judgment within the practical nurse's scope of practice by minimizing risks associated with diuretic therapy. Verifying two patient identifiers prevents medication administration errors. Monitoring daily weights provides essential data to evaluate fluid volume status and prevent complications. Recognizing new-onset resting tachycardia as a potential early compensatory sign of hypovolemia correctly prompts the nurse to withhold the medication and escalate the finding to the registered nurse.

Step-by-Step Solution

1
Analyze the client's clinical scenario and prescribed treatment.
The client has heart failure and is receiving furosemide, a loop diuretic that reduces fluid volume but can cause electrolyte loss and hypovolemia.
Understanding the medication's mechanism of action highlights the risk for hypovolemia, electrolyte imbalances (like hypokalemia), and physiological instability.
2
Evaluate each nursing action against the practical nurse scope of practice and safety standards.
The nurse must verify patient identifiers, measure daily weights accurately, and escalate early signs of hypovolemia such as tachycardia. The nurse must avoid giving IV push medications, ignoring critical laboratory values, or disregarding hypotensive vital signs.
The primary objective is the reduction of risk potential, which requires strict adherence to scope of practice and prompt recognition of clinical deterioration.

Key Concept

Reduction of Risk Potential (Scope of Practice and Complication Prevention)
Estimated Time:1m 30s
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Topics

Reduction of Risk Potential

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