A hospitalized client is receiving IV furosemide (Lasix) to treat stage 2 hypertension. Which assessment finding related to the medication requires prompt collaboration with the health care provider?

5-hour urine output total of 300 mL

Serum potassium level of 3.0 mEq/L

Current blood pressure of 141/80 mm Hg

Serum glucose level of 135 mg/dL

Answer and Explanation

The Correct Answer is B

A. 5-hour urine output total of 300 mL: This urine output is low, but it may not immediately indicate a serious issue without additional context. However, monitoring for adequate urine output is important.
B. Serum potassium level of 3.0 mEq/L: This is the correct choice. A serum potassium level of 3.0 mEq/L indicates hypokalemia, a serious side effect of furosemide, which can lead to cardiac arrhythmias and requires immediate intervention.
C. Current blood pressure of 141/80 mm Hg: Although the blood pressure is still elevated, it is not as urgent as correcting hypokalemia. The medication’s effectiveness should be monitored, but it is not an immediate concern.
D. Serum glucose level of 135 mg/dL: This level is slightly elevated but not critically high, and it does not require immediate action related to furosemide use.

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Correct Answer is D

Explanation

A. Level of consciousness: While important, it follows the assessment of vital signs to ensure the client's overall stability.
B. Condition of drains: This is relevant but not as immediate as assessing the stability of vital signs.
C. Appearance of the surgical dressing: This is important but secondary to ensuring the client’s vital signs are stable.
D. Stability of vital signs: This is the most critical next assessment after ensuring a patent airway, as vital signs reflect the client's immediate physiological status and stability.

A. A 47-year-old client who reports two loose stools with a serum sodium of 139 mmol/L B. A 71-year-old client with a calcium level of 8.9 mg/dL and a negative Trousseau sign C. A 52-year-old client with fluid volume excess and BUN of 18 mg/dL D. A 60-year-old client with a serum potassium of 3.2 mEq/L and heart palpitations

Correct Answer is D

Explanation

A. A 47-year-old client who reports two loose stools with a serum sodium of 139 mmol/L: Although diarrhea can lead to electrolyte imbalances, a serum sodium level of 139 mmol/L is within normal range, so this client is not the highest priority.
B. A 71-year-old client with a calcium level of 8.9 mg/dL and a negative Trousseau sign: A calcium level of 8.9 mg/dL is slightly low but not critically low, especially with a negative Trousseau sign. This client is stable compared to others.
C. A 52-year-old client with fluid volume excess and BUN of 18 mg/dL: A BUN of 18 mg/dL indicates mild elevation, and fluid volume excess can be managed with adjustments in treatment; this client does not require immediate priority.
D. A 60-year-old client with a serum potassium of 3.2 mEq/L and heart palpitations: A potassium level of 3.2 mEq/L indicates hypokalemia, which can cause serious cardiac issues and symptoms like palpitations. This client requires urgent attention to address the potential risk of cardiac complications.

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A hospitalized client is receiving IV furosemide (Lasix) to treat stage 2 hypertension. Which assessment finding related to the medication requires prompt collaboration with the health care provider?

Nursing Test Bank

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