An assigned client with chronic heart failure is scheduled to receive morning medications at 0900. The prescriptions include oral lisinopril 10 mg, oral spironolactone 25 mg, and an oral potassium chloride 20 mEq supplement. The morning electronic health record reveals a blood pressure of 134/82 mm Hg, a heart rate of 76 beats/min, and a serum potassium level of 5.8 mEq/L (5.8 mmol/L). Based on the practical nursing scope of practice, which action is the priority?
- Withhold the lisinopril, spironolactone, and potassium chloride, and immediately notify the registered nurse.Answer
- BAdminister the medications as prescribed, assuming an elevated potassium level is an expected compensatory response in heart failure.
- CWithhold the potassium chloride supplement, but independently proceed with administering the lisinopril and spironolactone.
- DCalculate and administer half of the prescribed potassium chloride dose to maintain electrolyte balance without causing further toxicity.
Answer
The priority action is to withhold the lisinopril, spironolactone, and potassium chloride, and immediately notify the registered nurse.
A serum potassium level of 5.8 mEq/L indicates severe hyperkalemia (normal is 3.5-5.0 mEq/L). Lisinopril is an ACE inhibitor that causes potassium retention. Spironolactone is a potassium-sparing diuretic. Administering these medications, along with a direct potassium supplement, would drastically increase the client's potassium level, placing them at immediate risk for life-threatening cardiac dysrhythmias such as ventricular fibrillation. The practical nurse must practice within their scope by withholding all three dangerous medications and immediately notifying the RN or provider for further orders.
Step-by-Step Solution
Key Concept
Hyperkalemia contraindicates the administration of ACE inhibitors, potassium-sparing diuretics, and potassium supplements; the PN must withhold these and notify the RN.
Estimated Time:2m 0s