The nurse is preparing to administer IV furosemide (Lasix) to a client with hypertension. What is the most important finding to report to the health care provider?

Blood glucose level of 175 mg/dl.

Orthostatic systolic BP decrease of 12 mm Hg

Serum potassium level of 3.0 mEq

Current blood pressure (BP) reading of 166/94 mm Hg

Answer and Explanation

The Correct Answer is C

The most important finding to report to the health care provider would be the serum potassium level of 3.0 mEq. This is an extremely low potassium level (normal range is typically 3.5-5.0 mEq/L), which can indicate a potentially life-threatening condition called hypokalemia. Furosemide (Lasix) is a diuretic medication that can cause potassium loss in the urine, and a low potassium level can lead to serious cardiac and muscle abnormalities. It is crucial to report this finding promptly to the health care provider for appropriate intervention and monitoring.

Blood glucose level of 175 mg/dL: While an elevated blood glucose level can be a concern, especially for individuals with diabetes, it is not the most critical finding in this situation. The client's primary concern is hypertension, and the administration of IV furosemide is aimed at managing blood pressure. The elevated blood glucose level should still be addressed and monitored, but it is not as urgent as the low potassium level.

Orthostatic systolic BP decrease of 12 mm Hg: Orthostatic hypotension refers to a significant decrease in blood pressure upon standing up. While it is important to assess and manage orthostatic changes, a decrease of 12 mm Hg in systolic blood pressure alone may not be considered clinically significant. It could be a normal response for some individuals. However, if the client experiences symptoms such as dizziness or lightheadedness upon standing, further evaluation may be necessary. Nonetheless, it is not as urgent as the low potassium level.

Current blood pressure reading of 166/94 mm Hg: While this blood pressure reading indicates hypertension, it is not the most critical finding to report in this situation. The nurse is preparing to administer furosemide (Lasix), which is a medication commonly used to treat hypertension. It is expected that the blood pressure will be high before administering the medication. The goal is to monitor the blood pressure after the administration to assess the effectiveness of the medication.

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Correct Answer is D

Explanation

Hypertension, or high blood pressure, is often referred to as the "silent killer" because it typically does not cause noticeable symptoms until it has already caused damage to target organs such as the heart, blood vessels, kidneys, or brain. It is crucial for the client to understand that even if they do not experience symptoms, untreated or poorly controlled hypertension can lead to serious complications, including heart disease, stroke, kidney problems, and more.

While dietary changes and increasing physical activity are important lifestyle modifications for managing hypertension, it is not accurate to state that most people can control their blood pressure through these measures alone. Hypertension is a complex condition influenced by multiple factors, and many individuals require additional interventions, such as medication, to effectively manage their blood pressure.

Annual blood pressure checks are indeed important to monitor the effectiveness of treatment and ensure that blood pressure remains within the target range. However, this information is secondary to the understanding that hypertension is typically asymptomatic until target organ damage occurs.

Recognizing the potential risks associated with untreated or uncontrolled hypertension can motivate the client to adhere to their treatment plan and make necessary lifestyle changes.

A. "Make an appointment with the dietitian for teaching.” B. "Check your blood pressure at home at least once a day." C. "Increase your dietary intake of high-potassium foods.” C. "Move slowly when moving from lying to sitting to standing.” D. "Move slowly when moving from lying to sitting to standing.”

Correct Answer is C

Explanation

Enalapril (Vasotec) is an angiotensin-converting enzyme (ACE) inhibitor medication commonly used to treat hypertension. One of the potential side effects of ACE inhibitors is hyperkalemia, which is an elevated level of potassium in the blood. Therefore, it is generally recommended for patients taking ACE inhibitors to avoid excessive intake of high-potassium foods.

The charge nurse should intervene because advising the client to increase their dietary intake of high-potassium foods contradicts the precautions associated with taking enalapril. Consuming high-potassium foods while taking this medication can potentially lead to an increased risk of hyperkalemia, which can have serious health consequences.

Let's review the other statements made by the nurse:

"Make an appointment with the dietitian for teaching": This is an appropriate statement as it encourages the client to seek professional guidance on dietary management of hypertension. A dietitian can provide valuable information on healthy eating habits and strategies to reduce blood pressure.

"Check your blood pressure at home at least once a day": This is also an appropriate statement as it promotes self-monitoring of blood pressure, which is important for clients with hypertension. Regular monitoring helps the client track their progress and detect any changes that may require medical attention.

"Move slowly when moving from lying to sitting to standing": This is a correct statement as it advises the client to practice orthostatic precautions. ACE inhibitors, including enalapril, can cause orthostatic hypotension, a drop in blood pressure upon standing. Moving slowly can help prevent dizziness and falls.

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The nurse is preparing to administer IV furosemide (Lasix) to a client with hypertension. What is the most important finding to report to the health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which information is most important for the nurse to include when teaching a client newly diagnosed with hypertension?

Correct Answer is D

Explanation

The charge nurse observes a new registered nurse (RN) doing discharge teaching for a client with hypertension who has a new prescription for enalapril (Vasotec). Which statement of the nurse to the patient would require the charge nurse's intervention?

Correct Answer is C

Explanation

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