A serum potassium level of 3.2 mEq/L is reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) due. Choose the best nursing action.

Administer the furosemide, then notify the HCP of potassium results.

Administer both drugs, then notify the HCP of potassium results.

Withhold both drugs and explain to the patient that the medications are contraindicated with hyperkalemia.

Administer the spironolactone, then notify the HCP of potassium results.

Answer and Explanation

The Correct Answer is D

Choice A reason:
Administering furosemide in this scenario would further lower the serum potassium level, as furosemide is a loop diuretic known for causing potassium loss through urine. This action could worsen the patient’s hypokalemia, leading to severe complications such as cardiac arrhythmias. Therefore, administering furosemide in the presence of hypokalemia is inappropriate and could put the patient at significant risk.
Choice B reason:
Administering both spironolactone and furosemide together without addressing the hypokalemia would not be safe. While spironolactone is a potassium-sparing diuretic, combining it with furosemide could negate its potassium-sparing effects. Furthermore, administering furosemide when hypokalemia is present could cause further electrolyte imbalance. Proper evaluation of the patient's condition and selective administration of the medications are crucial in this case.
Choice C reason:
Withholding both medications and attributing the decision to contraindications with hyperkalemia is incorrect because the reported potassium level (3.2 mEq/L) reflects hypokalemia, not hyperkalemia. Misinterpreting the lab result could delay appropriate treatment, such as correcting the potassium level or safely administering a medication that would not exacerbate the hypokalemia. Proper communication with the healthcare provider is necessary for effective patient care.
Choice D reason:
Administering spironolactone is the best action in this scenario because it is a potassium-sparing diuretic. By administering spironolactone, the risk of worsening hypokalemia is minimized. Notifying the healthcare provider about the low potassium level ensures appropriate monitoring and any necessary interventions, such as potassium supplementation. This approach is both safe and effective in managing the patient’s current condition while adhering to standard nursing practices.

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Correct Answer is C

Explanation

Choice A reason: Suggesting the use of adult incontinence briefs for nighttime only may help manage incontinence during the night, but it does not address the primary issue of urinary retention caused by a flaccid bladder. Incontinence briefs are a passive approach and do not prevent urinary retention or the complications associated with it, such as urinary tract infections and kidney damage. Additionally, it does not empower the patient to actively manage their urinary retention.
Choice B reason: Assisting the patient to the commode every 2 hours during the day can help to some extent in managing urinary retention. However, this approach requires constant assistance and is not practical for long-term management, especially when the patient is alone or in settings where frequent assistance is not available. This method also does not ensure complete bladder emptying, which is crucial for preventing urinary tract infections and other complications.
Choice C reason: Teaching the patient how to self-catheterize is the most appropriate and effective action for managing urinary retention caused by a flaccid bladder. Self-catheterization allows the patient to empty the bladder regularly and completely, reducing the risk of urinary tract infections, bladder distention, and kidney damage. It also provides the patient with a sense of control and independence in managing their condition. Self-catheterization is a standard and recommended practice for individuals with neurogenic bladder dysfunction due to multiple sclerosis.
Choice D reason: Encouraging decreased evening intake of fluid can help reduce nighttime urination, but it does not address the issue of urinary retention caused by a flaccid bladder. Decreasing fluid intake is not a comprehensive solution and does not prevent complications associated with incomplete bladder emptying. It is important to manage fluid intake appropriately, but this should be part of a broader strategy that includes effective bladder emptying techniques like self-catheterization.

A. Jaundice B. Spider angiomas C. Lethargic D. Apical pulse regular with S1, S2 E. Abdomen moderately distended F. Dark amber urine G. Peripheral pulses are palpable H. 3+ pitting edema

Correct Answer is ["A","B","E","F","H"]

Explanation

Choice A reason: Jaundice is a common finding in cirrhosis due to impaired liver function, which leads to the accumulation of bilirubin in the blood. This causes the skin and the whites of the eyes to turn yellow.
Choice B reason: Spider angiomas are dilated blood vessels that appear on the skin and are often seen in patients with cirrhosis. They are caused by increased estrogen levels due to impaired liver function.
Choice C reason: Lethargy is a symptom of cirrhosis as the liver's ability to detoxify the blood is compromised, leading to fatigue and weakness.
Choice D reason: An apical pulse regular with S1, S2 is not specifically associated with cirrhosis. While it may be a normal finding, it does not indicate the presence of cirrhosis.
Choice E reason: Abdomen moderately distended is consistent with cirrhosis due to the accumulation of fluid in the abdominal cavity (ascites), which is a common complication of advanced liver disease.
Choice F reason: Dark amber urine is a sign of cirrhosis as the liver's ability to process bilirubin is impaired, leading to the excretion of conjugated bilirubin in the urine, which gives it a dark color.
Choice G reason: Peripheral pulses are palpable is not specifically associated with cirrhosis. While it may be a normal finding, it does not indicate the presence of cirrhosis.
Choice H reason: 3+ pitting edema is consistent with cirrhosis due to the retention of sodium and water, leading to swelling in the lower extremities.

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A serum potassium level of 3.2 mEq/L is reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) due. Choose the best nursing action.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which action should the nurse plan to take for a patient with multiple sclerosis who has urinary retention caused by a flaccid bladder?

Correct Answer is C

Explanation

Which assessment findings are consistent with cirrhosis? Select all that apply.

Correct Answer is ["A","B","E","F","H"]

Explanation

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