The nurse is providing care for four patients: Patient A, diagnosed with emphysema and has an oxygen saturation of 94% on room air; Patient B, who is postoperative with a hemoglobin level of 8.2 mg/dL (82 g/L); Patient C, newly admitted with a potassium level of 3.8 mEq/L (3.8 mmol/L); and Patient D, who is scheduled for an appendectomy and has a white blood cell (WBC) count of 14,000 mm² (14 x 10°/L). What action should the nurse take next?

Based on the questionand the known effects of furosemide, here’s how each assessment finding can be categorized:

• Potassium 3.1 mEq/L: This is anon-therapeutic side effect.Furosemide is a diuretic that increases the excretion of water, sodium, and potassium from the body.This can lead to hypokalemia, or low potassium levels.
• Prothrombin time/INR 2.2: This is likely anunrelated finding.Furosemide does not typically affect prothrombin time or INR.However, the patient is also taking warfarin, which is an anticoagulant known to increase INR.
• Urine output: 600 mL: This is atherapeutic result.Furosemide works by increasing the amount of urine the body makes, which helps reduce swelling and symptoms of fluid retention.

Choice A rationale

Assisting the spouse and carefully giving the patient small sips of water may seem like a compassionate action. However, it could potentially lead to aspiration if the patient’s swallowing reflex is compromised, which is common in stroke patients.

Choice B rationale

While obtaining thickening powder before providing any more fluids can help prevent aspiration in patients with dysphagia, it is not the immediate action the nurse should take. The nurse first needs to assess the patient’s swallowing reflex before deciding on the appropriate intervention.

Choice C rationale

The nurse should ask the spouse to stop and assess the patient’s swallowing reflex. This is the most immediate and appropriate action. Stroke patients often have impaired swallowing reflexes, which can lead to aspiration if not properly managed. By assessing the swallowing reflex, the nurse can determine the best course of action to ensure the patient’s safety.

Choice D rationale

Giving the spouse a straw to help facilitate the patient’s drinking is not the best course of action. Straws can increase the risk of aspiration in patients with impaired swallowing reflexes. The nurse should first assess the patient’s swallowing reflex before deciding on the appropriate intervention.