The prescriber orders furosemide 80 mg for a patient who has been retaining extra fluid after surgery. The nurse notes the following: BP of 142/88 (lying) and 108/60 (sitting); daily weight of 154 lb, a 1-lb drop from day before; serum potassium of 2.8 mEq/L.
What should the nurse do?
Administer medication.
Contact provider.
Hold medication
Give potassium supplement
The Correct Answer is B
The nurse should contact the provider before administering furosemide because the patient has a low serum potassium level of 2.8 mEq/L, which is below the normal range of 3.5 to 5.0 mEq/L. Furosemide is a diuretic that can cause potassium loss and worsen hypokalemia, which can lead to cardiac arrhythmias, muscle weakness, and fatigue. The nurse should also monitor the patient’s blood pressure, weight, and urine output, as furosemide can lower blood pressure and cause dehydration.
Choice A. Administer medication is wrong because the nurse should not give furosemide without checking with the provider first, as it could be harmful to the patient with low potassium.
Choice C. Hold medication is wrong because the nurse should not withhold furosemide without a valid reason or an order from the provider, as it could cause fluid overload and worsen the patient’s condition.
Choice D. Give potassium supplement is wrong because the nurse should not give potassium supplement without an order from the provider, as it could cause hyperkalemia or interact with other medications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is because a PTT (partial thromboplastin time) test measures how long it takes for blood to clot. A normal PTT range is between 25 to 35 seconds. If the patient’s PTT is too long and greater than 80 seconds, it means their blood is taking too long to clot and they are at risk of bleeding excessively. The nurse should notify the doctor and expect an order to hold the dose of heparin, a type of anticoagulant that prevents blood clots by prolonging the PTT.
Choice A is wrong because continuing with the same dosage of heparin would not correct the prolonged PTT and could cause more bleeding problems for the patient.
Choice C is wrong because increasing the dosage of heparin would further prolong the PTT and increase the risk of bleeding.
Choice D is wrong because decreasing the dosage of heparin would not be enough to bring the PTT back to normal range and would still pose a bleeding risk for the patient.
Correct Answer is A
Explanation
Food high in potassium should be avoided for clients taking ACE inhibitors. ACE inhibitors are drugs that block the conversion of angiotensin I to angiotensin II, which is a potent vasoconstrictor and also stimulates the secretion of aldosterone. Aldosterone is a hormone that increases the reabsorption of sodium and water and the excretion of potassium in the kidneys. By inhibiting angiotensin II, ACE inhibitors lower blood pressure and reduce the loss of potassium. However, this can also lead to hyperkalemia, which is a high level of potassium in the blood that can cause cardiac arrhythmias and muscle weakness.Therefore, clients taking ACE inhibitors should limit their intake of foods that are rich in potassium, such as bananas, oranges, tomatoes, potatoes, spinach, beans, nuts, and salt substitutes.
Choice B is wrong because a low sodium diet is recommended for clients taking ACE inhibitors.
A low sodium diet can help lower blood pressure and reduce fluid retention, which are beneficial effects for clients with hypertension, heart failure, or chronic kidney disease.A low-potassium diet should aim for potassium intake of less than 50 or 75 mmol/day and sodium intake of less than 60 mmol/day for hypertensive patients with chronic kidney disease.
Choice C is wrong because adequate fluid intake is not contraindicated for clients taking ACE inhibitors.
Adequate fluid intake can help prevent dehydration and maintain kidney function, especially in patients with diabetes or nephropathy.However, excessive fluid intake may worsen heart failure or edema in some patients, so fluid intake should be individualized and monitored according to the patient’s condition and response to therapy.
Choice D is wrong because foods low in potassium are not harmful for clients taking ACE inhibitors.
Foods low in potassium do not affect the serum potassium level or the risk of hyperkalemia in clients taking ACE inhibitors.However, foods low in potassium may not provide enough dietary potassium for normal cellular functions, so a balanced diet that includes moderate amounts of potassium-rich foods is advisable.
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