Marvin is transferred from the ICU to the Tele/Neuro unit 24 hours after receiving tPA. He has left sided hemiplegia with some dysphagia. What nursing interventions should be part of his plan of care? Select all that apply.

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.

Choice A reason: Hepatic encephalopathy is a severe complication of cirrhosis caused by elevated serum ammonia levels. When the liver is unable to effectively remove ammonia from the blood due to cirrhosis, ammonia accumulates and crosses the blood-brain barrier, leading to neurological symptoms such as confusion, altered mental status, and even coma. This condition is directly related to the liver's impaired ability to detoxify the blood, making it the most consistent complication associated with elevated serum ammonia levels.
Choice B reason: Jaundice is a common symptom of cirrhosis, but it is not directly caused by elevated serum ammonia levels. Jaundice occurs due to the liver's inability to process bilirubin, a byproduct of red blood cell breakdown, leading to its accumulation in the blood and tissues. While jaundice is a sign of liver dysfunction, it is not specifically linked to ammonia levels.
Choice C reason: Ascites is the accumulation of fluid in the abdominal cavity and is a common complication of cirrhosis. It occurs due to portal hypertension and hypoalbuminemia, which result from liver dysfunction. Although ascites is a significant complication, it is not directly caused by elevated serum ammonia levels.
Choice D reason: Peripheral neuropathies are nerve damage that can occur in various conditions, but they are not typically associated with elevated serum ammonia levels in cirrhosis. Peripheral neuropathies can result from nutritional deficiencies, metabolic disorders, or other underlying conditions, but they are not a direct consequence of ammonia accumulation.