Adult Health
1400 A 24-year-old male is admitted with confusion, lethargy, and dyspnea after participating in a marathon. The client was seen drinking large amounts of plain water. Crackles notes to all lung fields with a productive cough. 1+ deep tendon reflexes, 2+ regular pulses, active bowel sounds, diaphoretic.
Vitals: 99.0°F. 37.0°C, 97 bpm, 151/85 mm Hg, RR 30 breaths/min, O2 sat 85% on room air.
1415:
- Admit to intensive care unit (ICU)
- Seizure precautions
- 12-lead electrocardiogram (ECG)
- Daily weight
- 3% saline at 100 mL/hr
- Serum sodium levels every 2 hours
- Furosemide 40 mg intravenous (IV) push × 1 dose
- Insert an indwelling urinary catheter
- Nitroglycerin 600 mcg IV bolus, then continuous IV infusion at 100 mcg/min (titrate per protocol)
- Non-invasive positive pressure ventilation (BiPAP) with FiO₂ titrated to maintain SpO₂ > 92%
The nurse is planning the care for the client.
➢ For each potential intervention, click to specify whether the intervention is indicated or not indicated for the client.
- A. neurological assessments every hour
- B. insertion of a nasogastric tube (NGT)
- C. initiate seizure precautions
- D. infusion of hypertonic saline
- E. albuterol via nebulizer
- F. intravenous diuretics
- G. supplemental oxygen
- H. cooling measures using ice packs and fans
- I. insertion of a urinary catheter
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