A practical nurse (PN) is caring for a client who is 18 hours postoperative following a pa… — NCLEX-PN

A practical nurse (PN) is caring for a client who is $18$ hours postoperative following a partial bowel resection. The client is scheduled to receive a routine dose of oral furosemide for a history of heart failure. The client's admission baseline blood pressure was $142/86\text{ mmHg}$ . The current vital signs are blood pressure $98/64\text{ mmHg}$ , heart rate $108\text{ beats per minute}$ , and respiratory rate $20\text{ breaths per minute}$ . The morning comprehensive metabolic panel indicates a serum potassium level of $2.8\text{ mEq/L}$ ( $2.8\text{ mmol/L}$ ). Which action should the PN take?

Withhold the furosemide and immediately notify the registered nurse of the client's vital signs and laboratory results.Cevap
B
Administer the scheduled furosemide, as the client's current blood pressure reading is sufficient to maintain organ perfusion.
C
Document the abnormal potassium level in the electronic health record and proceed with administering the medication.
D
Conduct a comprehensive cardiovascular assessment to determine if the client is hemodynamically stable enough to receive the medication.

Cevap

The practical nurse should withhold the furosemide and immediately notify the registered nurse of the client's unstable vital signs and critical laboratory results.

Furosemide is a potassium-wasting loop diuretic that reduces fluid volume. Administering this medication to a client with a critically low potassium level (

2.8\text{ mEq/L}

) and borderline vital signs indicating potential early shock (hypotension and tachycardia) could precipitate cardiovascular collapse or lethal dysrhythmias. The practical nurse must withhold the dose to reduce the risk of harm and immediately escalate these findings to the registered nurse.

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Analyze the client's vital signs and compare them to the admission baseline.

The blood pressure has dropped significantly from

142/86\text{ mmHg}

98/64\text{ mmHg}

, and the heart rate is elevated at

108\text{ beats per minute}

Recognizing a downward trend in blood pressure combined with tachycardia is essential to identifying potential early hypovolemic shock or hemorrhage in a postoperative client.

Evaluate the morning laboratory results.

The serum potassium level is

2.8\text{ mEq/L}

, which is critically low (normal is typically

3.5

5.0\text{ mEq/L}

Hypokalemia increases the risk of life-threatening cardiac dysrhythmias and must be identified before administering medications that affect electrolyte balance.

Determine the pharmacological impact of the prescribed medication.

Furosemide is a loop diuretic that promotes fluid excretion and potassium loss.

Administering furosemide would exacerbate both the client's hypovolemia (worsening the shock state) and hypokalemia (increasing dysrhythmia risk).

Apply the practical nurse's scope of practice to the situation.

The medication must be withheld, and the findings must be urgently escalated to the registered nurse.

The PN cannot independently alter the medical plan or perform a comprehensive assessment, but must intervene by holding harmful medications and reporting critical changes.

Anahtar Kavram

Reduction of Risk Potential: Recognizing and Escaping Clinical Deterioration

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