A nurse is caring for a patient with cirrhosis and ascites who has been receiving IV furosemide for the past 24 hours. Which assessment finding should be the nurse's highest priority?

Severe hypokalemia (K+ 2.8 mEq/L) is life-threatening in heart failure patients due to high risk of cardiac arrhythmias, requiring immediate intervention. Other findings like low urine output or hypotension are less urgent.

Core Nursing Explanation Key Concept Analysis: This question tests the nurse's ability to prioritize patient care based on the ABCs (Airway, Breathing, Circulation) and the principle of Key Point! life-threatening complications of diuretic therapy. The patient has Cirrhosis with Ascites and is receiving a potent Loop diuretic (Furosemide). While all findings require attention, the nurse must identify which one poses the most immediate danger to the patient's life.

Answer Rationale: The correct answer is ③ Blood pressure of 90/60 mmHg. This finding indicates Key Point! hypotension, a critical sign of hypovolemia (decreased circulating blood volume) and potential Shock. In a patient with cirrhosis and ascites, aggressive diuresis can rapidly deplete intravascular volume, leading to Renal hypoperfusion and Hepatorenal syndrome, a fatal complication. A BP of 90/60 mmHg, especially if it represents a significant drop from the patient's baseline, is a Key Point! circulatory emergency that must be addressed immediately to prevent organ failure. This aligns with the "Circulation" component of the ABC priority framework.

Distractor Analysis:
Watch out for confusion! ① Urine output of 30 mL/hr for the past 4 hours: While this output is below the normal minimum of 30 mL/hr (or 0.5 mL/kg/hr), it is a common and expected consequence of effective diuresis and hypovolemia. It is a sign of the problem (hypovolemia), but the life-threatening consequence of that problem is the hypotension. The low urine output itself, at 30 mL/hr, is not immediately life-threatening, whereas the low BP is.
Watch out for confusion! ② Serum sodium level of 135 mEq/L: This value is at the very low end of normal (135-145 mEq/L). It indicates mild Hyponatremia, which is common in cirrhosis due to water retention. However, it is not severe or acute enough to be the highest priority. Severe hyponatremia (

Nursing Clinical Practice Guide Clinical Scenario: Mr. Johnson, 58, admitted with decompensated alcoholic cirrhosis and tense ascites. He is on a regimen of IV furosemide 40 mg daily and spironolactone 100 mg daily. On your morning assessment, he reports feeling dizzy when standing up. You check his vitals: BP 92/58 mmHg (down from 118/76 yesterday), HR 112 bpm, RR 18, SpO2 96%.

Nursing Intervention Strategy: 1. Immediate Safety & Assessment: Keep the patient on bed rest. Re-check BP in both arms, lying and standing (if safe), to confirm orthostatic hypotension. Perform a full set of vital signs. Auscultate heart and lung sounds. Assess skin turgor, mucous membranes, and jugular venous pressure (JVP). 2. Communication & Collaboration: Notify the physician/NP immediately. Report the trend: "BP has dropped significantly to 92/58 with tachycardia, patient reports dizziness. He is on IV furosemide for ascites." 3. Medication Management: Key Point! Hold the next scheduled dose of IV furosemide as per protocol or after receiving an order. Do not administer it. 4. Monitoring & Evaluation: Increase frequency of vital sign monitoring (e.g., every 15-30 minutes until stable). Strictly monitor intake and output (I&O). Weigh the patient daily (same scale, same time). Assess for worsening signs: decreased level of consciousness, chest pain, or oliguria (