A transgender client taking spironolactone (Aldactone) is in the internal medicine clinic reporting heart palpitations. What action by the nurse takes priority?
a. Draw blood to test serum potassium.
b. Have the client lie down.
c. Obtain a STAT electrocardiogram (ECG).
d. Take a set of vital signs.
ANS: C
Spironolactone is a potassium-sparing diuretic, and hyperkalemia can cause cardiac dysrhythmias. The nurse's priority is to obtain an ECG, then to facilitate a serum potassium level being drawn. Having the client lie down and obtaining vital signs are also important care measures, but do not take priority.
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