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 ["A","B"]

Explanation

Choice A reason: Bleeding is a high-risk complication for patients with pancytopenia because of the low platelet count. Platelets are crucial for blood clotting, and their deficiency leads to an increased risk of spontaneous bleeding and difficulty in stopping bleeding once it starts. This can result in significant blood loss and complications if not managed promptly.
Choice B reason: Infection is another high-risk complication for patients with pancytopenia due to the low white blood cell count. White blood cells are essential for fighting infections, and their deficiency makes patients more susceptible to bacterial, viral, and fungal infections. These infections can be severe and difficult to control, leading to further complications and increased morbidity.
Choice C reason: Seizures are not typically associated with pancytopenia. Seizures are more commonly linked to neurological conditions, electrolyte imbalances, or other underlying medical issues rather than low blood cell counts.
Choice D reason: Neurogenic shock is not a common complication of pancytopenia. Neurogenic shock occurs due to a disruption in the autonomic nervous system, often resulting from spinal cord injuries or severe central nervous system damage, rather than low blood cell counts.
Choice E reason: Pulmonary edema is not directly related to pancytopenia. Pulmonary edema involves fluid accumulation in the lungs, often due to heart failure, kidney disease, or other causes, rather than low blood cell counts.

A. The patient is alert and oriented x4. B. The patient reports nausea. C. The abdomen is tender to palpation. D. The patient is 60 years old. E. The patient has dark amber urine. F. The patient's oral temperature is 102.4°F. G. The patient is voiding without difficulty.

Correct Answer is ["B","C","E","F"]

Explanation

Choice A reason: The patient is alert and oriented x4. This indicates that the patient is fully aware of their surroundings and does not require follow-up for this finding.
Choice B reason: The patient reports nausea. Nausea can be a symptom of many underlying conditions, including gastrointestinal issues or medication side effects, and requires follow-up to determine the cause and provide appropriate treatment.
Choice C reason: The abdomen is tender to palpation. Abdominal tenderness can indicate inflammation, infection, or other abdominal pathology, which requires follow-up to identify the underlying cause and provide appropriate management.
Choice D reason: The patient is 60 years old. This is a demographic detail and does not indicate a medical condition requiring follow-up.
Choice E reason: The patient has dark amber urine. Dark amber urine can be an indication of dehydration or other underlying conditions that require follow-up to identify and address the cause.
Choice F reason: The patient's oral temperature is 102.4°F. A fever indicates the presence of an infection or other health issue that needs to be investigated and managed.
Choice G reason: The patient is voiding without difficulty. This indicates that there are no issues with urinary function, so no follow-up is required for this finding.

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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 potential complication would the nurse identify as a high risk for a patient admitted to the hospital with pancytopenia? Select all that apply.

Correct Answer is ["A","B"]

Explanation

Which four patient assessment findings require follow-up by the nurse? Select all four that apply.

Correct Answer is ["B","C","E","F"]

Explanation

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