Difficulty: Medium
Average Score: 87%
Simulated
The nurse is preparing to administer spironolactone (Aldactone) and furosemide (Lasix) at 0900 to a client diagnosed with ascites. Review of 0600 laboratory results shows serum sodium 130 mEq/L (136-145 mEq/L) and potassium 3.1 mEq/L (3.5-5.0 mEq/L). Which action should the nurse take first?
Correct answer
D
Rationale
Requesting a dietary consult is useful but not the most immediate action needed. Ordering a 2 gram sodium restriction diet is important but not addressing the immediate issue of electrolyte imbalance. Fluid restriction may be considered but not before addressing the electrolyte issues. Holding the spironolactone and furosemide is the correct action, as administering these could exacerbate the existing hypokalemia and hyponatremia, increasing the risk of adverse effects.