NCLEX-RNReduction of Risk PotentialMedium
A client receiving furosemide for heart failure reports leg cramps and generalized weakness. The serum potassium level is 2.9 mEq/L (normal 3.5–5.0 mEq/L). Which action should the nurse take?
- AInstruct the client to perform a Valsalva maneuver to slow the heart rate
- BEncourage the client to eat foods high in sodium
- CNotify the health care provider and anticipate an order for potassium replacement
- DRestrict the client's fluid intake to reduce swelling
Show answer & explanationAnswer & explanation
Correct answer: C. Notify the health care provider and anticipate an order for potassium replacement
A potassium level of 2.9 mEq/L is significantly below normal and places the client at risk for life-threatening cardiac dysrhythmias, especially with diuretic therapy. The nurse should notify the provider for potassium replacement and initiate cardiac monitoring.
Why the other options are wrong
- A. Valsalva maneuver is unrelated to correcting hypokalemia and could trigger dysrhythmias.
- B. Sodium intake does not address potassium loss and may worsen fluid retention in heart failure.
- D. Fluid restriction does not correct the electrolyte imbalance.
Hypokalemia
Serum potassium below 3.5 mEq/L, often caused by diuretics, vomiting, or diarrhea, leading to muscle weakness and cardiac dysrhythmia risk.
- Normal range: 3.5–5.0 mEq/L
- Loop diuretics (e.g., furosemide) promote potassium loss
- ECG changes include flattened T waves and U waves
Memory trick: Low K = Low energy, Weak muscles, Flat T waves