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Difficulty: HardReduction of Risk Potential

A practical nurse (PN) receives a telephone call from the laboratory reporting a critical serum potassium level of 6.26.2 mEq/L for a client. The client's morning medications, which include the potassium-sparing diuretic spironolactone, are currently due. In what order should the PN perform the following actions to minimize the risk of complications? (Arrange the steps in the correct order of priority.)

  1. 1Write down the critical laboratory result and read it back to the laboratory personnel.
  2. 2Withhold the scheduled dose of the potassium-sparing diuretic spironolactone.
  3. 3Assess the client's vital signs and apical heart rhythm.
  4. 4Report the critical laboratory finding and assessment data to the healthcare provider.
  5. 5Document the critical value, the provider notification, and the withheld medication in the medical record.

Answer

The correct priority sequence is to first verify the lab result, withhold the contraindicated medication, assess the client's cardiac status, notify the provider, and finally document the event.
When receiving a critical laboratory value via telephone, the absolute first priority is safety and accuracy, which requires writing down and reading back the result. Next, the nurse must immediately protect the client from further harm by holding any medications that could worsen the condition (spironolactone). Before notifying the provider, the nurse must assess the client (vital signs, apical pulse) to have a complete clinical picture for the SBAR report. Notification of the RN and provider follows to secure emergency orders. Finally, all steps and communications are documented in the client's medical record.

Step-by-Step Solution

1
Write down and read back the critical laboratory result.
Ensures the accuracy of the critical information received over the telephone.
Verifying verbal communication is a mandatory safety standard to prevent life-threatening errors.
2
Withhold the scheduled dose of spironolactone.
Prevents the introduction of additional potassium or retention of existing potassium.
Spironolactone is a potassium-sparing diuretic that would exacerbate the critical hyperkalemia and increase the risk of cardiac arrest.
3
Assess vital signs and apical heart rhythm.
Identifies any immediate clinical manifestations of severe hyperkalemia.
Current assessment data is required to communicate the client's immediate physiological status to the provider effectively.
4
Report the findings to the supervising registered nurse (RN) and healthcare provider.
Escalates the critical situation to the appropriate clinicians.
The provider must prescribe emergency pharmacological interventions (such as calcium gluconate, regular insulin, or sodium polystyrene sulfonate) to lower the serum potassium level.
5
Document all findings and actions in the medical record.
Creates a permanent legal and clinical record.
Documentation should always occur after the client's immediate safety is secured and care has been escalated.

Key Concept

Prioritizing nursing actions for critical laboratory values and medication safety
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Topics

Reduction of Risk Potential

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