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Zorluk: OrtaReduction of Risk Potential

A practical nurse is caring for a client with a history of heart failure who is scheduled to receive a routine morning dose of oral furosemide. The client's morning basic metabolic panel reveals a serum potassium level of 2.7 mEq/L (mmol/L). During data collection, the client reports feeling generalized muscle weakness, and the practical nurse notes an irregular apical pulse of 106 beats per minute. What is the most appropriate action for the practical nurse to take?

  1. A
    Administer the furosemide as prescribed and document the laboratory results in the medical record.
  2. B
    Instruct the client to remain on strict bed rest and reassess the borderline tachycardia in one hour.
  3. Withhold the morning dose of furosemide and immediately alert the supervising registered nurse.Cevap
  4. D
    Independently obtain a bag of intravenous potassium chloride and initiate a continuous infusion.

Cevap

The correct action is to withhold the morning dose of furosemide and immediately notify the registered nurse.
The client's serum potassium level of 2.7 mEq/L is critically low (normal range is typically 3.5 to 5.0 mEq/L). Furosemide is a loop diuretic that causes potassium excretion. Administering this medication would further lower the potassium level, increasing the risk of life-threatening cardiac dysrhythmias, which are already suggested by the client's irregular heart rate and muscle weakness. The practical nurse must safely withhold the drug and escalate this critical finding to the registered nurse or healthcare provider to reduce risk potential.

Adım Adım Çözüm

1
Analyze the laboratory results against normal reference ranges.
The serum potassium level of 2.7 mEq/L is critically low (normal is 3.5 to 5.0 mEq/L).
Identifying abnormal laboratory values is essential to determine the client's current physiological stability.
2
Evaluate the clinical findings in the context of the laboratory results.
The client's muscle weakness and irregular tachycardia are classic clinical manifestations of severe hypokalemia.
Correlating lab data with physical symptoms confirms the client is experiencing adverse physiological effects.
3
Determine the pharmacological impact of the scheduled medication.
Furosemide is a loop diuretic that promotes the excretion of potassium in the urine.
Administering this medication would further deplete the client's already critical potassium levels.
4
Select the safest nursing intervention based on the practical nurse's scope of practice.
The practical nurse must withhold the contraindicated medication and escalate the critical findings to the registered nurse or provider.
Preventing harm by holding the drug and ensuring a higher level of care is initiated fulfills the requirement to reduce risk potential.

Anahtar Kavram

Recognizing critical laboratory values and mitigating risks associated with pharmacological therapies
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Konular

Reduction of Risk Potential

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