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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Choice A reason:
Monitoring for signs of dehydration is essential because Mr. Carter's symptoms (fatigue, nausea, and jaundice) and laboratory results indicate acute hepatitis A, which can cause significant fluid loss due to nausea and reduced oral intake. Assessing hydration status ensures timely intervention to prevent complications such as hypovolemia. Additionally, high bilirubin levels and elevated liver enzymes suggest hepatic dysfunction, which may impair the body's ability to maintain fluid balance.
Choice B reason:
Educating Mr. Carter on proper hand hygiene is crucial to prevent the transmission of hepatitis A, which is highly contagious and spreads via the fecal-oral route. Since Mr. Carter has recently traveled to an area with poor sanitation, providing education on hygiene practices is an immediate priority to protect others. Proper handwashing with soap and clean water significantly reduces the risk of spreading the infection.
Choice C reason:
Encouraging a high-protein diet to repair liver damage is not appropriate during the acute phase of hepatitis A. Protein metabolism requires significant liver function, which is impaired in Mr. Carter’s case due to elevated ALT and AST levels. Emphasizing adequate hydration and balanced nutrition (without overloading the liver with protein) is more suitable. Dietary recommendations for hepatitis A focus on small, frequent meals and avoiding foods that burden liver function.
Choice D reason:
Administering intravenous antibiotics is unnecessary because hepatitis A is a viral infection, not bacterial. Antibiotics do not address viral infections and would not benefit Mr. Carter’s recovery. Supportive care, including hydration, rest, and symptom management, is the mainstay of treatment for viral hepatitis A.
Choice E reason:
Advising rest and limiting physical activity is vital to support Mr. Carter’s recovery. Fatigue and jaundice indicate that his liver is under significant strain, and rest helps reduce metabolic demands on the liver, allowing it to heal more effectively. Light activity may be reintroduced as symptoms improve, but physical exertion should be avoided during the acute phase.
Choice F reason:
Educating the patient about the need for lifelong hepatitis A vaccination is unnecessary because recovery from hepatitis A usually provides lifelong immunity. Vaccination is more relevant for individuals who are at risk and have not been exposed to the virus. Mr. Carter’s current care plan should focus on managing the acute phase of the disease and preventing transmission to others.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A reason: Asking the nursing assistant to determine if Marvin can safely sit in a bedside chair is not appropriate. Safety assessments, especially for patients with recent neurological events, should be done by a registered nurse or a physical therapist. This ensures that any nuanced clinical signs indicating instability or risk are recognized and addressed promptly.
Choice B reason: Passive range of motion (ROM) exercises are essential for patients with hemiplegia to prevent complications such as muscle atrophy, joint contractures, and decreased circulation. Regularly performing these exercises can maintain the health of the muscles and joints, promote better blood flow, and help in maintaining some degree of flexibility in the affected limbs.
Choice C reason: Assessing neurologic status is crucial in patients who have had a recent stroke and received tPA treatment. Frequent neurologic assessments help in monitoring for any changes or signs of deterioration. This includes checking consciousness, pupil response, motor function, and sensory perception. Changes in these parameters can indicate complications or the need for immediate medical interventions.
Choice D reason: Coordinating with speech therapy for a swallowing evaluation is essential because Marvin has dysphagia. Swallowing assessments by a speech therapist can determine the patient's ability to swallow safely and the appropriate dietary modifications needed to prevent aspiration, a common risk in patients with dysphagia. This is vital to prevent pneumonia or other respiratory complications.
Choice E reason: Using pillows and positioning devices to maintain proper body alignment is important in preventing complications such as pressure ulcers, muscle contractures, and discomfort. Proper positioning can also assist in maintaining better respiratory function and overall comfort. It also prevents the development of deformities and promotes functional posture, which is especially important for patients with hemiplegia.
Choice F reason: Pulling on his arm to position him on his side is inappropriate and can cause injury, especially in a patient with hemiplegia. This technique can lead to shoulder dislocations or increased pain. Instead, proper repositioning techniques using assistive devices and help from additional staff members should be employed to ensure safe and effective movement of the patient.
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