# A nurse is caring for a 68-year-old patient with acute heart failure who has been receiving IV furosemide for 3 days. The patient's current vital signs are: BP 90/60 mmHg, HR 110 bpm, RR 22/min, O2 sat 94% on 2L nasal cannula. Laboratory results show: K+ 2.8 mEq/L, Na+ 128 mEq/L, BUN 45 mg/dL, creatinine 2.1 mg/dL. Which nursing intervention should the nurse implement first? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543573 > language: ko > subject: Next Gen NCLEX ## 문제 A nurse is caring for a 68-year-old patient with acute heart failure who has been receiving IV furosemide for 3 days. The patient's current vital signs are: BP 90/60 mmHg, HR 110 bpm, RR 22/min, O2 sat 94% on 2L nasal cannula. Laboratory results show: K+ 2.8 mEq/L, Na+ 128 mEq/L, BUN 45 mg/dL, creatinine 2.1 mg/dL. Which nursing intervention should the nurse implement first? ## 보기 1. Hold the next dose of furosemide and notify the healthcare provider immediately **✔ 정답** 2. Administer prescribed potassium chloride supplement 3. Increase the oxygen flow rate to 4L per nasal cannula 4. Encourage increased fluid intake to improve hydration status **정답: 1** ## 해설 The patient shows signs of overdiuresis with hypotension, low urine output, and severe electrolyte imbalances (hypokalemia, hyponatremia). Holding furosemide and notifying the provider is the priority to prevent further harm. Other options address specific issues but do not stop the causative treatment. ## 심화 해설 Clinical Deterioration in Acute Heart Failure: Prioritizing the Nursing Response The patient is exhibiting signs of both hemodynamic instability and severe electrolyte disturbances as a complication of aggressive loop diuretic therapy. The nurse must recognize that the presentation reflects a critical intersection of hypovolemia, electrolyte depletion, and acute kidney injury (AKI), which requires immediate cessation of the offending agent and provider notification before any other intervention. Deconstructing the Clinical Picture The data cluster reveals a patient in a state of decompensation driven by the pharmacological effects of furosemide. Loop diuretics, while being the first-line decongestive therapy for heart failure, can induce profound hemodynamic and metabolic shifts, especially in older adults after several days of IV administration. * Hemodynamic Profile: The blood pressure of 90/60 mmHg and reflex tachycardia of 110 bpm indicate relative hypovolemia and a low cardiac output state. The aggressive diuresis has likely reduced the effective circulating volume, leading to hypotension and compensatory sympathetic nervous system activation. * Renal Function: The BUN of 45 mg/dL and creatinine of 2.1 mg/dL signify an acute kidney injury, with a BUN:creatinine ratio suggesting a prerenal etiology. This is a direct hemodynamic consequence of the intravascular volume depletion and reduced renal perfusion pressure. * Electrolyte Disturbances: The serum potassium of 2.8 mEq/L represents severe hypokalemia, and the sodium of 128 mEq/L indicates significant hyponatremia. Both are well-known consequences of loop diuretic use, which blocks the Na-K-2Cl cotransporter in the thick ascending limb of the loop of Henle, causing massive urinary loss of sodium and potassium. This entire picture is a classic manifestation of what the literature describes as an adverse response to decongestive therapy, where the hemodynamic and renal consequences of diuresis can mimic or exacerbate cardiorenal syndrome. The cited evidence emphasizes that impaired renal perfusion and neurohormonal activation are key factors in poor outcomes during decongestion [1]. The patient is no longer simply being treated for fluid overload; they have been pushed into a state of iatrogenic hypovolemia and prerenal failure. Applying the Nursing Process and Prioritization The nurse must use clinical judgment to sequence interventions based on urgency. The question asks for the first action, which is a classic NCLEX-RN prioritization scenario. * Why Option 1 is Correct (Hold Furosemide and Notify Provider): The root cause of the patient's hypotension, AKI, and electrolyte imbalances is the ongoing administration of a potent loop diuretic in the setting of probable intravascular depletion. The priority is to stop the causative agent. Continuing furosemide would further worsen the prerenal state, deepen the hypokalemia, and risk precipitating a life-threatening cardiac arrhythmia. The nurse must immediately hold the medication and communicate this critical change in status, including the new-onset AKI and severe electrolyte abnormalities, to the healthcare provider. This action directly addresses the underlying mechanism of the deterioration [1]. Why Option 2 is Delayed (Administer Potassium Supplement): While correcting the severe hypokalemia of 2.8 mEq/L is crucial to prevent cardiac arrhythmias, it is not the first* action. Administering potassium without first stopping the drug that is causing the potassium wasting is an incomplete and potentially dangerous approach. The provider must be notified to obtain comprehensive orders that address both the cause (diuretic) and the consequence (electrolyte loss) in the context of the new AKI, which will drastically alter potassium excretion and requires careful repletion. * Why Option 3 is Inappropriate (Increase Oxygen): The patient’s oxygen saturation is 94% on 2L, which is within an acceptable range for many patients with acute heart failure. While respiratory status is always a high priority, there is no immediate evidence of a respiratory crisis. Increasing oxygen does not address the life-threatening cascade of hypovolemic shock, prerenal failure, and severe hypokalemia. It is a supportive measure, not a corrective one for the primary problem. * Why Option 4 is Harmful (Encourage Fluid Intake): This intervention is contraindicated. The patient was initially admitted for acute heart failure with fluid overload. The current hypotension and prerenal failure are likely due to over-diuresis, not a simple fluid deficit that should be corrected by encouraging oral intake. Aggressive fluid administration could rapidly tip the patient back into acute pulmonary edema. The management of this complex scenario requires careful provider-led decisions, often involving a reduction or temporary cessation of diuretics, and possibly cautious, controlled IV fluid replacement, not an unmonitored oral fluid push [2]. The clinical priority is to recognize that the treatment has become the primary threat. The nurse’s first and most critical safety intervention is to discontinue the harmful agent and immediately alert the provider to the patient’s decompensation, which is characterized by new-onset prerenal AKI and severe electrolyte disturbances resulting from aggressive loop diuretic therapy. ## 임상 시나리오 Recognizing Furosemide Toxicity in Heart FailureWhen Diuresis Becomes Dangerous The cluster of new hypotension (90/60 mmHg), reflex tachycardia, and a rising BUN:creatinine ratio after aggressive IV furosemide points to prerenal acute kidney injury (AKI) from intravascular volume depletion. This is a medical emergency. The first and most critical nursing action is to hold the furosemide and notify the provider immediately. Continuing the drug will worsen hypovolemia, further drop renal perfusion, and deepen the life-threatening hypokalemia (2.8 mEq/L). CautionDo not confuse this with a simple electrolyte imbalance. Administering potassium or fluids before stopping the causative agent is unsafe. A potassium supplement alone will not stabilize the patient and risks hyperkalemia if renal function worsens. Increasing fluids is contraindicated in heart failure. ## 핵심 개념 - **Prerenal AKI** — Kidney injury caused by reduced blood flow to the kidneys, often from hypovolemia or low cardiac output, indicated here by a high BUN:creatinine ratio. - **Loop Diuretic Toxicity** — Adverse effects from drugs like furosemide, including severe fluid depletion, hypotension, and electrolyte wasting (hypokalemia, hyponatremia). - **Hemodynamic Instability** — A state of abnormal blood pressure and heart rate (e.g., hypotension 90/60, tachycardia 110) indicating the cardiovascular system is failing to perfuse organs adequately. ## 같은 주제 문제 - [A nurse is caring for multiple patients on a medical-surgical unit. Which patient should t…](https://mymerci.kr/pages/nclex_q.php?qn_id=543567) - [A nurse is triaging patients in the emergency department. Which patient should the nurse a…](https://mymerci.kr/pages/nclex_q.php?qn_id=543568) - [A nurse is caring for patients in a pediatric unit. Which patient should the nurse assess …](https://mymerci.kr/pages/nclex_q.php?qn_id=543569) - [A nurse is caring for multiple patients during a busy shift. Which patient should the nurs…](https://mymerci.kr/pages/nclex_q.php?qn_id=543570) - [A nurse is triaging patients in the emergency department. Which patient requires the most …](https://mymerci.kr/pages/nclex_q.php?qn_id=543571) - [A nurse is caring for a 68-year-old patient with chronic obstructive pulmonary disease (CO…](https://mymerci.kr/pages/nclex_q.php?qn_id=543572) - [A nurse is caring for a 72-year-old patient with acute exacerbation of chronic obstructive…](https://mymerci.kr/pages/nclex_q.php?qn_id=543574) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._