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 A
Explanation
Hypokalemia is a condition of low potassium levels in the blood, which can be caused by diuretics such as furosemide (Lasix) that increase the excretion of potassium in the urine. Potassium is an important electrolyte that helps regulate the function of nerves and muscles, including the heart.Low potassium levels can cause symptoms such as confusion, tremors, muscle cramps, and nausea, which are consistent with the patient’s presentation.
Choice B, renal failure, is wrong because furosemide is used to treat fluid retention and edema caused by kidney disease, not to cause it.Renal failure would also cause symptoms such as decreased urine output, swelling, fatigue, and shortness of breath, which are not mentioned in the question.
Choice C, hyperkalemia, is wrong because hyperkalemia is a condition of high potassium levels in the blood, which can be caused by kidney disease or certain medications that decrease the excretion of potassium in the urine.Hyperkalemia can cause symptoms such as weakness, irregular heartbeat, paralysis, and chest pain, which are different from the patient’s symptoms.
Choice D, heart failure, is wrong because furosemide is also used to treat fluid retention and edema caused by heart failure, not to cause it.Heart failure would also cause symptoms such as shortness of breath, coughing, fatigue, and rapid weight gain, which are not mentioned in the question.
Normal ranges for potassium levels in the blood are 3.5 to 5.0 milliequivalents per liter (mEq/L) for adults and 3.4 to 4.7 mEq/L for children.
A level below 3.5 mEq/L is considered hypokalemic and a level above 5.0 mEq/L is considered hyperkalemic.
Correct Answer is B
Explanation
PT stands for prothrombin time, which is a measure of how long it takes the blood to clot.
INR stands for international normalized ratio, which is a way of standardizing the PT results across different laboratories.
Warfarin is a blood thinner that works by inhibiting the production of vitamin K-dependent clotting factors in the liver.
Therefore, warfarin prolongs the PT and increases the INR.The PT/INR test is used to monitor the effectiveness of warfarin therapy and adjust the dose accordingly.
Choice A is wrong because PTT stands for partial thromboplastin time, which is another measure of blood clotting time, but it reflects the activity of different clotting factors than PT.PTT is used to monitor heparin therapy, not warfarin therapy.
Choice C is wrong because aPTT stands for activated partial thromboplastin time, which is a variation of PTT that uses an activator to speed up the clotting time.Like PTT, aPTT is used to monitor heparin therapy, not warfarin therapy.
Choice D is wrong because ACT stands for activated clotting time, which is a measure of the whole blood clotting time.ACT is used to monitor high-dose heparin therapy during certain procedures, such as cardiac bypass surgery or angioplasty.
The normal ranges for these tests may vary depending on the laboratory and the method used, but generally, they are:
• PT: 10 to 13 seconds
• INR: 0.8 to 1.2 (without warfarin) or 2.0 to 3.0 (with warfarin)
• PTT: 25 to 35 seconds
• aPTT: 30 to 40 seconds
• ACT: 70 to 120 seconds
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