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 reviews the client's assessment findings and laboratory results.
➢ For each client finding below, click to specify if the finding is consistent with the disease process of Pneumonia, Pulmonary Edema, or Heat Stroke.
Each finding may support more than one (1) disease process.
Each column must have at least one (1) response option selected.
- A. electrolyte imbalance
- B. productive cough
- C. tachypnea
- D. altered mental status
- E. tachycardia
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