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Difficulty: MediumPharmacological Therapies

A practical nurse is caring for a client who is scheduled to receive a morning dose of oral furosemide. During the pre-administration assessment, the nurse notes the client's blood pressure is 86/52 mm Hg, heart rate is 114 beats/min, and the morning serum potassium level is 3.1 mEq/L (3.1 mmol/L). Which action should the practical nurse take?

  1. Withhold the furosemide and immediately report the findings to the registered nurse.Answer
  2. B
    Administer the scheduled dose of furosemide and document the assessment findings in the medical record.
  3. C
    Administer half of the prescribed furosemide dose to prevent further decreases in blood pressure.
  4. D
    Place the client in a supine position, wait one hour, and administer the furosemide if the blood pressure increases.

Answer

The practical nurse should withhold the furosemide and immediately report the findings to the registered nurse.
The correct action is to withhold the medication and notify the registered nurse. Furosemide is a loop diuretic that promotes the excretion of water and potassium. The client is already exhibiting signs of hypovolemia (hypotension and tachycardia) and hypokalemia (potassium 3.1 mEq/L, normal is 3.5-5.0 mEq/L). Administering furosemide would worsen both conditions, potentially leading to severe cardiovascular collapse or lethal dysrhythmias. The practical nurse must recognize these critical findings, withhold the drug, and escalate the situation.

Step-by-Step Solution

1
Analyze the client's vital signs and laboratory results.
The blood pressure (86/52 mm Hg) and heart rate (114 beats/min) indicate potential hypovolemia. The potassium level (3.1 mEq/L) indicates hypokalemia.
Pre-administration assessment is critical to ensure medication safety and identify contraindications.
2
Evaluate the pharmacological effects of furosemide against the client's current status.
Furosemide is a loop diuretic that causes fluid loss (lowering blood pressure) and potassium excretion (worsening hypokalemia).
Administering the drug would exacerbate the client's current dangerous physiological state.
3
Determine the appropriate nursing intervention based on the practical nurse scope of practice.
The safest and most appropriate action is to withhold the medication and escalate the critical findings to the supervising registered nurse or healthcare provider.
Practical nurses must recognize adverse conditions, withhold unsafe medications, and communicate findings promptly.

Key Concept

Pre-administration Assessment and Withholding Criteria for Diuretics
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Topics

Pharmacological Therapies

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