NCLEX STYLE CS

CASE STUDY 1

The nurse is caring for a client with a history of heart failure & atrial fibrillation, who is prescribed Metoprolol (Lopressor) & Spironolactone (Aldactone).

The client’s VS: HR 50/min, BP 68/50 mmHg; & UO < 30 mL/hr.

Current lab shows a serum potassium of 6.8 mEq/L (normal 3.5.5.2).

Which is a priority nursing intervention?

1. Hold the Metoprolol & Spironolactone until the client's BP 120/80 mmHg.

2. Administer Metoprolol & Spironolactone as ordered because the vital signs are as expected.

3. Hold Metoprolol & Spironolactone, administer ordered IV NS at 125 mL/hr & PRN PO Kayexalate.

4. Contact the provider to obtain an order for IV lasix ( furosemide DI)

You need to know: abnormal VS, meds s/e, anormal labs, s/s of

hyperkalemia, appropriate interventions, & prioritization


3. Hold Metoprolol & Spironolactone, administer ordered IV NS at 125 mL/hr & PRN PO Kayexalate.

RATIONALE:

  • Abnormal Vital Signs: The client's heart rate (HR) is 50 beats per minute, and blood pressure (BP) is 68/50 mmHg, which are both critically low. This hypotension and bradycardia may be exacerbated by Metoprolol, a beta-blocker, which lowers heart rate and blood pressure.

  • Medication Side Effects:

    • Metoprolol: Can cause bradycardia and hypotension, which are already present in the client.

    • Spironolactone: A potassium-sparing diuretic that can increase serum potassium levels, and the client's potassium is already critically high (6.8 mEq/L).

  • Abnormal Labs: Serum potassium of 6.8 mEq/L indicates hyperkalemia, which is a critical condition that can lead to life-threatening cardiac arrhythmias.

  • Signs and Symptoms of Hyperkalemia: May include muscle weakness, fatigue, and serious cardiac issues, including arrhythmias or cardiac arrest.


INTERVENTIONS:

  • Appropriate Interventions:

    • Hold Metoprolol and Spironolactone: These medications could worsen the hypotension and hyperkalemia.

    • Administer IV Normal Saline (NS): Helps to increase fluid volume and improve blood pressure.

    • Kayexalate (Sodium Polystyrene Sulfonate): Used to treat hyperkalemia by helping to remove excess potassium from the body.

  • Prioritization: The most immediate concerns are the critically low blood pressure, low heart rate, and high potassium levels. The intervention focuses on stabilizing these parameters to prevent further complications.

CASE STUDY 2

0655: Alert and oriented × 4; moves all extremities but states at home right arm felt weak and tingling. Now arm feels “more normal.” PERRLA; CNs intact. Lung sounds clear; S1S2 present. BS present × 4. Bilateral carotid bruits noted. T 99°F (37.2°C); HR 88 beats/min; RR 18 breaths/min; BP 168/92 mm Hg; SpO2 96% on RA. Long history of type 2 diabetes mellitus, hypertension, and alcohol use. 69-pack-year smoking history. Random non fasting serum glucose = 231 mg/dL (12.8 mmol/L).

What potential condition the client is likely experiencing?

→ client is likely experiencing a transient ischemic attack (TIA)


RATIONALE:
Symptoms:

  • The client reported weakness and tingling in the right arm earlier, which are common signs of a TIA or stroke.

  • These symptoms have now improved, which is characteristic of a TIA, where symptoms are temporary and resolve within 24 hours.

  • Risk Factors:

    • Hypertension: The client has an elevated BP of 168/92 mmHg, a significant risk factor for stroke.

    • Diabetes Mellitus: Long-standing diabetes increases the risk of cerebrovascular disease.

    • Smoking History: A 69-pack-year smoking history significantly raises the risk for atherosclerosis and vascular events.

    • Alcohol Use: Chronic alcohol use can contribute to hypertension and other cardiovascular issues.

    • Carotid Bruits: Indicates the presence of turbulent blood flow, likely due to carotid artery stenosis, which can increase the risk of stroke or TIA.

  • Blood Glucose: The elevated random non fasting serum glucose (231 mg/dL) indicates poor glucose control, contributing to vascular complications.


Two Appropriate Nursing Actions:

  1. Administer Antihypertensive Medication: To control the elevated blood pressure (BP 168/92 mmHg), which is crucial in reducing the risk of stroke or further cerebrovascular events.

  2. Provide Education on Lifestyle Changes: Educate the client about smoking cessation, alcohol moderation, and the importance of managing diabetes and hypertension to reduce the risk of future TIAs or strokes.

Two Parameters to Monitor:

  1. Neurological Status: Monitor for any changes in neurological signs, such as weakness, tingling, or altered mental status, which could indicate worsening or recurrence of symptoms.

  2. Blood Pressure: Regular monitoring of blood pressure to ensure it is within target ranges, as uncontrolled hypertension is a major risk factor for stroke.