A practical nurse (PN) is reviewing the electronic health record of an adult client admitt… — NCLEX-PN

A practical nurse (PN) is reviewing the electronic health record of an adult client admitted with an exacerbation of heart failure. The client is scheduled to receive a dose of oral furosemide. The morning laboratory results indicate a serum potassium level of $3.1\text{ mEq/L}$ . The client's most recent vital signs include a blood pressure of $96/58\text{ mm Hg}$ and a heart rate of $114\text{ beats/min}$ . Which of the following is the most appropriate action for the PN to take?

A
Administer the furosemide as scheduled and encourage the client to consume potassium-rich foods.
B
Proceed with the medication administration since mild hypotension is an expected finding in heart failure.
Withhold the furosemide and immediately notify the registered nurse (RN).Cevap
D
Give the medication and instruct the unlicensed assistive personnel (UAP) to closely monitor the client's vital signs.

Cevap

The most appropriate action is to withhold the furosemide and immediately notify the registered nurse (RN).

The correct action is to withhold the furosemide and notify the registered nurse (RN). Furosemide is a loop diuretic that depletes potassium and fluid volume. The client's serum potassium is critically low (

3.1\text{ mEq/L}

), placing them at immediate risk for cardiac dysrhythmias. Furthermore, the blood pressure of

96/58\text{ mm Hg}

and heart rate of

114\text{ beats/min}

indicate potential hypovolemia or compromised perfusion. Giving the medication would dangerously worsen both the electrolyte imbalance and the hemodynamic instability. It is within the practical nurse's scope to withhold a potentially harmful medication and report critical assessment findings to the supervising RN.

Adım Adım Çözüm

Analyze the client's laboratory values in relation to the prescribed medication.

The serum potassium level is

3.1\text{ mEq/L}

, which indicates hypokalemia. Furosemide is a potassium-wasting loop diuretic that will further lower this critical value.

Administering a loop diuretic to a hypokalemic client can lead to life-threatening cardiac dysrhythmias.

Evaluate the client's current vital signs for potential contraindications.

The blood pressure of

96/58\text{ mm Hg}

and heart rate of

114\text{ beats/min}

suggest hypovolemia or decreased cardiac output.

Diuretics reduce intravascular volume; administering the dose could dangerously worsen the client's hypotension and tachycardia.

Determine the appropriate nursing intervention within the practical nurse (PN) scope of practice.

The PN must withhold the scheduled medication and escalate the critical findings to the supervising RN.

The PN acts to maintain client safety and collaborates with the RN when assessment findings require clinical judgment beyond the PN scope.

Anahtar Kavram

Safe administration of diuretics requires assessing for and responding to critical fluid volume deficits and electrolyte imbalances, specifically hypokalemia and hypotension.

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