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 plans to evaluate the client's response to the treatment plan.
➢ For each medication below, identify the finding(s) the nurse should monitor to evaluate the client's response to the medication.
Each category may have more than one (1) finding. Each category must have at least one (1) finding.
- A. intravenous (IV) furosemide
- B. 3% saline solution
- C. intravenous (IV) nitroglycerin
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