Mrs. Ramirez is an 81-year-old female who arrives at theemergency department (ED) with increasing confusion, fever,lethargy, and hypotension experienced for the last three days. Hervital signs are as follows: blood pressure 80/56 mm Hg, temperature100.0° F, heart rate 100 beats/min, and respiratory rate 28breaths/min. Her husband tells the physician that she has a pastmedical history of hypertension and type 2 diabetes. Her dailymedications include lisinopril/hydrochlorothiazide (Prinzide) 20mg/25 mg, metformin (Glucophage) 1000 mg twice a day, pravastatin(Pravachol) 40 mg at night, and calcium citrate and vitamin D(Citracal) two tablets every day. She was just seen by the primarycare provider last week and her blood pressure medication wasincreased from once a day to twice a day. The ED physician ordersthe following:
Diet:nothing by mouth
Laboratorytests: complete blood count (CBC) and chemistry panel, urinalysis,blood cultures
STATelectrocardiogram (ECG) and chest x-ray
Start0.9% normal saline intravenously to run at 100 mL/hr
The results are as follows:
ECG:sinus tachycardia
Chestx-ray: lung fields without any noted infiltrates or masses;moderate degenerative changes noted to thoracic spine
A. What is the purpose of 0.9% normal saline IVfluid therapy for Mrs. Ramirez? Select all that apply.
- To restore hydration status
2. To increase her blood pressure
3.To provide nutritional support while she cannoteat
4.To reduce her fever
5.To correct her hyponatremia
6.Clear sound on assessment of thelungs.
B. What nursing assessment findingswould indicate that Mrs. Ramirez is experiencing fluid volumeoverload while receiving IV therapy? Select all thatapply.
1.Weight loss of 2 lb in 24 hours
2.Weight gain of 2 lb in 24 hours
3.An increase in respiratory rate from 2 hoursago
4.Increase in confusion since the morningassessment
5.A wet productive cough
6.Clear lung sounds heard in anterior and posteriorfields
C. In reviewing Mrs. Ramirez’s medicalhistory, what factors likely put her at risk for fluid volumedeficit and electrolyte imbalances?
1.Fever and diuretic therapy
2.Hypotension and tachycardia
3.Type 2 diabetes and renal insufficiency
4.Rapid respiratory rate and hypertension
D. What information is mostimportant to document in caring for Mrs. Ramirez while she isreceiving IV therapy? Select all that apply.
1.Frequent assessment of her IV site during infusion offluids
2.Her ability to care for herself when she is dischargedfrom the hospital
3.Her level of consciousness every shift
4.Documentation of IV tubing changes
5.A 24-hour recall of the foods that she haseaten
6.Assessment of her pain using a 1 to 10 painscale
