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Zorluk: OrtaReduction of Risk Potential

A practical nurse (PN) is preparing to administer a scheduled dose of oral furosemide to a client admitted with heart failure exacerbation. The client's morning vital signs include a blood pressure of 94/56 mm Hg and a heart rate of 112 beats/min. A recent laboratory report indicates a serum potassium level of 2.6 mEq/L. Which action is the priority for the PN?

  1. Withhold the dose of furosemide and immediately notify the registered nurse (RN).Cevap
  2. B
    Administer the furosemide as prescribed and document the laboratory results in the chart.
  3. C
    Reassess the client's vital signs in one hour to evaluate if the tachycardia resolves.
  4. D
    Verify the client's identity using two identifiers before giving the medication.

Cevap

The correct action is to withhold the dose of furosemide and immediately notify the registered nurse (RN).
Furosemide is a potent loop diuretic that promotes the excretion of fluid and electrolytes, including potassium. A serum potassium level of 2.6 mEq/L is critically low (normal range is 3.5 to 5.0 mEq/L) and places the client at immediate risk for life-threatening cardiac dysrhythmias. Furthermore, the client's borderline hypotension and tachycardia suggest hypovolemia. Administering furosemide would exacerbate both the potassium depletion and the fluid volume deficit. The priority action to reduce risk potential is to withhold the medication and escalate these critical findings to the RN.

Adım Adım Çözüm

1
Evaluate the client's laboratory results against normal reference ranges.
The serum potassium level of 2.6 mEq/L is critically low (normal is 3.5 to 5.0 mEq/L).
Identifying abnormal labs is essential before administering medications that can further alter those levels.
2
Analyze the client's vital signs.
The blood pressure (94/56 mm Hg) is low and the heart rate (112 beats/min) is elevated.
Tachycardia combined with hypotension often indicates fluid volume deficit (hypovolemia) or early shock.
3
Determine the pharmacological effects of furosemide.
Furosemide is a loop diuretic that causes the kidneys to excrete excess fluid and potassium.
Understanding the drug's mechanism reveals that giving it will worsen both the hypokalemia and the hypovolemia.
4
Select the safest nursing action within the PN scope of practice.
The medication must be withheld, and the abnormal findings must be escalated to the RN for immediate intervention.
The PN must reduce risk potential by preventing medication-induced complications and ensuring timely collaborative care.

Anahtar Kavram

Prioritizing client safety by recognizing critical laboratory values and vital signs that contraindicate scheduled medication administration.
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Konular

Reduction of Risk Potential

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