Examkin

Question

Difficulty: EasyReduction of Risk Potential

During morning medication rounds, a nurse reviews the chart of a client diagnosed with heart failure. The client is scheduled to receive a daily dose of oral furosemide. The morning laboratory report indicates a serum potassium level of 2.6 mEq/L2.6\text{ mEq/L}. What is the most appropriate immediate action for the nurse to take?

  1. Withhold the furosemide and immediately notify the registered nurse of the laboratory results.Answer
  2. B
    Administer the prescribed dose and document the findings in the electronic health record.
  3. C
    Change the administration route to an intravenous push to manage the client's fluid volume more carefully.
  4. D
    Proceed with administering the medication as long as the client's current heart rate and blood pressure are stable.

Answer

Withhold the furosemide and immediately notify the registered nurse of the laboratory results.
The correct action is to withhold the medication and notify the supervising registered nurse. A serum potassium level of 2.6 mEq/L2.6\text{ mEq/L} indicates severe hypokalemia (the normal range is approximately 3.53.5 to 5.0 mEq/L5.0\text{ mEq/L}). Because furosemide is a potassium-depleting loop diuretic, administering it would further lower the potassium level, placing the client at extremely high risk for potentially fatal cardiac arrhythmias.

Step-by-Step Solution

1
Identify the critical laboratory value.
The client's potassium level is 2.6 mEq/L2.6\text{ mEq/L} (normal is typically 3.53.5 to 5.0 mEq/L5.0\text{ mEq/L}), indicating severe hypokalemia.
Recognizing abnormal data is the first step in risk reduction before administering medications.
2
Correlate the laboratory value with the prescribed medication.
Furosemide is a loop diuretic known to cause potassium loss.
Administering the medication will worsen the client's hypokalemia, increasing the risk for fatal cardiac arrhythmias.
3
Determine the safest nursing intervention within the practical nurse scope of practice.
Withhold the medication and escalate the finding to the registered nurse or healthcare provider.
Preventing patient harm requires stopping the contraindicated medication and ensuring the care team is informed for further orders.

Key Concept

Recognizing critical laboratory values and withholding contraindicated medications to prevent adverse outcomes.
Rate this question

Topics

Reduction of Risk Potential

More questions from this topic