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Difficulty: MediumReduction of Risk Potential

The practical nurse is analyzing morning data for several assigned clients on a medical-surgical unit. Which client-specific finding represents an immediate risk to physiological safety and must be reported to the registered nurse?

  1. A client taking oral spironolactone whose morning serum potassium level is reported as 5.95.9 mEq/L (5.95.9 mmol/L).Answer
  2. B
    A client recovering from an appendectomy 2424 hours ago who exhibits a temperature of 99.4∘99.4^\circ F (37.4∘37.4^\circ C) and a heart rate of 8484 beats/min.
  3. C
    A client with chronic obstructive pulmonary disease whose morning arterial blood gas reveals a partial pressure of carbon dioxide (PaCO2PaCO_2) of 4848 mm Hg.
  4. D
    A client who requests to take their scheduled oral levothyroxine simultaneously with their morning breakfast tray.

Answer

The client taking spironolactone with a potassium level of 5.9 mEq/L requires immediate escalation.
Spironolactone is a potassium-sparing diuretic. A serum potassium level of 5.95.9 mEq/L (5.95.9 mmol/L) indicates significant hyperkalemia (normal range 3.53.5 to 5.05.0 mEq/L). If the nurse administers the scheduled dose, the client is at severe risk for life-threatening cardiac dysrhythmias. This critical laboratory value must be escalated to the registered nurse immediately so the medication can be safely held and the healthcare provider notified.

Step-by-Step Solution

1
Analyze the laboratory finding for the client taking spironolactone.
The potassium level is 5.95.9 mEq/L, which is significantly above the normal range of 3.53.5 to 5.05.0 mEq/L.
Identifying critical laboratory values is the first step in clinical risk reduction.
2
Determine the pharmacological effect of the prescribed medication.
Spironolactone is a potassium-sparing diuretic that causes the body to excrete sodium and retain potassium.
Understanding medication mechanisms helps predict and prevent severe adverse effects.
3
Evaluate the risk potential of the abnormal finding.
Hyperkalemia places the client at immediate risk for life-threatening cardiac dysrhythmias if further potassium is retained.
Prioritization requires identifying the most acute and immediate threat to a client's life.
4
Determine the appropriate nursing action.
The practical nurse must immediately report this critical finding to the registered nurse.
Immediate escalation ensures the medication is held and medical interventions to lower the potassium level can be initiated.

Key Concept

Recognizing Critical Laboratory Values and Medication Adverse Effects
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Topics

Reduction of Risk Potential

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