The nurse reviews the assigned clients' laboratory results and medication administration records. Which finding is the highest priority for the nurse to follow-up with the health care provider?

Question

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This client who was prescribed spironolactone (Aldactone), a potassium-sparing diuretic that counteracts the potassium loss caused by other diuretics, has high serum potassium (normal 3.5-5.0 mEq/L [3.5-5.0 mmol/L]). The continuation of this medication puts this client at risk for life-threatening hyperkalemia-induced cardiac dysrhythmias. This finding is of highest priority for the nurse to follow-up with the health care provider (HCP). (Option A) This client has positive gram-negative blood cultures. Tobramycin, an aminoglycoside antibiotic drug, is used to treat serious gram-negative bacterial infections. There is no indication to follow-up with the HCP. (Option B) BNP is a hormone released by heart muscle in response to mechanical stress (stretching). BNP levels are usually elevated (normal <100 pg/mL [100 ng/L]) in clients with heart failure, and the prescription for furosemide (Lasix), a loop diuretic, is expected. (Option D) This client has hyponatremia (normal 135-145 mEq/L [135-145 mmol/L]) and is receiving isotonic normal saline solution; there is no indication to follow-up with the HCP. Educational objective: A nurse should monitor clients receiving spironolactone, a potassium-sparing diuretic, for hyperkalemia. The continuation of this medication in the presence of an elevated serum potassium level puts a client at risk for life-threatening cardiac dysrhythmias.

The Nurse Reviews the Assigned Clients' Laboratory Results and Medication