Your patient is ordered a loop diuretic at 1000. Which finding below would require you to hold the dose and notify the physician for further orders?
Sodium level 144
Potassium level 1.5 mEq/L
Blood pressure 102/78
Calcium level 9 mg/L
The Correct Answer is B
Loop diuretics, such as furosemide, are known to cause potassium loss as they increase urine output. A potassium level of 1.5 mEq/L indicates severe hypokalemia (low potassium levels), which can be potentially dangerous and lead to various complications, including cardiac arrhythmias.
Hence, it is important to hold the dose of the loop diuretic and notify the physician so that appropriate interventions can be taken to address the low potassium level, such as prescribing potassium supplementation or adjusting the dosage of the loop diuretic.
A sodium level of 144 is within the normal range (135-145 mEq/L) and does not require immediate action.
A blood pressure of 102/78, although it may indicate hypotension, does not necessarily require holding the dose of the loop diuretic unless it is accompanied by other significant symptoms or clinical concerns.
A calcium level of 9 mg/dL falls within the normal range (8.5-10.5 mg/dL) and does not necessitate holding the loop diuretic dose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
Pain tolerance refers to the maximum level of pain that an individual can tolerate without significant distress. It is influenced by various factors, including psychological and emotional factors. While emotions such as anger, boredom, and introversion can have an impact on a person's pain perception and experience, sleep plays a significant role in pain tolerance. During sleep, the body is in a state of rest and relaxation, allowing for decreased sensory input and potentially reducing pain perception. Sleep provides an opportunity for the body to repair and heal, which can contribute to improved pain tolerance. Additionally, sleep promotes the release of endogenous opioids, which are natural pain-relieving substances produced by the body.
Correct Answer is D
Explanation
The development of nausea and increased upper abdominal bowel sounds after 24 hours of NG decompression in a patient with gastric outlet obstruction raises concerns for possible complications or changes in the patient's condition. Assessing the patient's vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, can provide important information about their circulatory status and overall stability.
While checking the patency of the NG tube is important, it is not the best immediate action in this situation. The nurse should first assess the patient's vital signs to ensure their stability before proceeding with further interventions.
Placing the patient in a recumbent position (lying down) or encouraging deep breathing and conscious relaxation may not address the underlying issue and could potentially exacerbate the symptoms. It is essential to assess the patient's vital signs and circulatory status to determine the appropriate course of action.
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