A practical nurse (PN) is preparing to administer morning medications, including digoxin and furosemide. When checking the client's chart, the PN discovers a new serum potassium result of mEq/L. Arrange the following actions in the correct priority sequence.
- 1Withhold the administration of the scheduled digoxin and furosemide.
- 2Assess the client's apical pulse and observe for signs of profound muscle weakness.
- 3Report the critical potassium level and the client's vital signs to the supervising registered nurse.
- 4Document the withheld medications, assessment findings, and the RN notification in the health record.
Cevap
The correct sequence is to first withhold the medications, then assess the client's apical pulse, report the findings to the registered nurse, and finally document the actions taken.
When a practical nurse identifies a critical laboratory value such as a potassium level of mEq/L, the immediate priority is client safety. The PN must first withhold any medications that could exacerbate the condition, such as furosemide (which wastes potassium) and digoxin (which becomes highly toxic in hypokalemia). Next, the PN must assess the client for active complications, specifically checking the apical pulse for arrhythmias. Once the assessment data is collected, the PN reports a complete clinical picture to the RN to facilitate prompt medical intervention. Finally, all findings and actions are thoroughly documented in the electronic health record.
Adım Adım Çözüm
Anahtar Kavram
Prioritization and Escalation of Critical Laboratory Values