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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A,D,B,E,C,F,G,H,I

Explanation

Ensure MDHCP has discussed risks and benefits of blood transfusion. (a)
Educate patient on signs and symptoms of transfusion reaction. (d)
Obtain cross match and send it to blood bank. (b)
Gain blood from bank, confirm correct patient, correct product, correct cross match with 2 RNs. (e)
Initiate transfusion through a large gauge IV per hospital protocol. (c)
Start transfusion slowly for the first 15 minutes and stay with patient for the first 15 minutes. (f)
Increase rate of transfusion and monitor patient frequently. (g)
Ensure transfusion is complete within 4 hours of starting. (h)
Continue to monitor patient for transfusion reaction for 24 hours following transfusion. (i)

Rationale:

Ensure MDHCP has discussed risks and benefits of blood transfusion: It's essential that the healthcare provider discusses with the patient the potential risks and benefits of receiving a blood transfusion. This step is crucial for informed consent.
Educate patient on signs and symptoms of transfusion reaction: Before starting the transfusion, the patient should be educated on what signs and symptoms to watch out for that might indicate an adverse reaction, such as fever, chills, hives, or shortness of breath.
Obtain cross match and send it to blood bank: A blood sample is taken from the patient to determine their blood type and to perform a crossmatch, which ensures that the donor blood is compatible with the patient's blood.
Gain blood from bank, confirm correct patient, correct product, correct cross match with 2 RNs: Once the blood is ready, two registered nurses (RNs) will verify the patient's identity, the blood product, and the crossmatch results to ensure everything is correct before proceeding.
Initiate transfusion through a large gauge IV per hospital protocol: The blood transfusion is started using a large gauge intravenous (IV) line, as per hospital protocols to ensure proper flow and reduce complications.
Start transfusion slowly for the first 15 minutes and stay with patient for the first 15 minutes: The transfusion is started at a slow rate to monitor for any immediate adverse reactions. The healthcare provider stays with the patient during this time to closely observe them.
Increase rate of transfusion and monitor patient frequently: If no adverse reactions are noted in the first 15 minutes, the rate of transfusion can be increased. The patient is monitored frequently throughout the transfusion for any signs of a reaction.
Ensure transfusion is complete within 4 hours of starting: Blood products should be transfused within 4 hours to minimize the risk of bacterial growth and to ensure the effectiveness of the transfusion.
Continue to monitor patient for transfusion reaction for 24 hours following transfusion: After the transfusion is complete, the patient is monitored for at least 24 hours for any delayed transfusion reactions, such as fever, allergic reactions, or other complications.

A. Cardiac dysrhythmias, Hypotension, and pain B. Fluid and electrolyte imbalance, Hypotension, and Wound dehiscence C. Inadequate diet, Wound dehiscence, Hypotension D. Infection, Fluid and electrolyte imbalance, and pain

Correct Answer is D

Explanation

Choice A reason: Cardiac dysrhythmias are not the primary concern in a patient with acute cholecystitis. Although severe pain can lead to stress on the cardiovascular system, it is not the main priority in this scenario. Hypotension can be a concern due to dehydration from vomiting, but pain management is addressed more comprehensively under fluid and electrolyte balance and infection control.
Choice B reason: Wound dehiscence is not relevant in this case as the patient has not undergone surgery yet. Fluid and electrolyte imbalance and hypotension are important considerations due to the patient’s nausea and vomiting, but wound dehiscence does not apply to her current state of care.
Choice C reason: The inadequate diet is a consideration due to the patient's inability to eat or drink, and hypotension is a risk due to dehydration. However, wound dehiscence is still not relevant since the patient has not had a surgical procedure yet. Preventing an inadequate diet is part of the broader management but not the immediate priority.
Choice D reason: Infection, fluid and electrolyte imbalance, and pain are the most relevant concerns for a patient with acute cholecystitis. The nasogastric tube and IV fluids are vital for managing her dehydration and electrolyte imbalances. The patient's high pain level (9/10) indicates severe discomfort that must be managed effectively. Additionally, with the insertion of a nasogastric tube and the risk of cholecystitis-related complications, preventing infection is a key priority.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Order the steps for completing a blood transfusion.

Correct Answer is A,D,B,E,C,F,G,H,I

Explanation

Based on the patient's current condition, the nurse recognizes that the patient's priority needs will be to prevent:

Correct Answer is D

Explanation

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.

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

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

How is Addison disease treated and clinically managed?

Which group of drugs will the nurse plan to include when teaching a patient who has a new diagnosis of peripheral artery disease (PAD)? Select all that apply:

Causative factors for the development of delirium include which of the following? Select all that apply.