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Awake, alert, oriented x 3. Skin warm and dry. Client’s morning weight is 58 kg (127.8 lb). Lung sounds clear to auscultation. Oxygen saturation is 95% on room air. Telemetry reveals normal sinus rhythm, rate 86/min. Lower extremities with 2+ pitting edema. Reports shortness of breath with ambulation. 1920: Awake, alert, oriented x 3. Skin warm and dry. Lung sounds with crackles bilaterally throughout. Oxygen saturation is 88% on room air. Oxygen @ 8 L/min applied as prescribed. Telemetry reveals sinus tachycardia, rate 125/min. Lower extremities with 3+ pitting edema. Reports increasing shortness of breath with ambulation and activities. Noted urine output for previous 24 hours 575 mL. Laboratory Results 1000: Brain Natriuretic Peptide 250 pg/mL (less than 100 pg/mL) 1930: Brain Natriuretic Peptide 1050 pg/mL (less than 100 pg/mL) 1920: ECG Interpretation: Sinus tachycardia, heart rate 125/min 1200: Increase valsartan to 80 mg daily Titrate oxygen for oxygen saturation greater than 95% Administer IV nitroglycerine for BNP greater than 1000 pg/mL Administer furosemide 80 mg intravenous push for urine output less than 720 mL/24 hr Which of the following interventions should the nurse implement with this client? Select all that apply. Obtain consent for a pericardiocentesis. Administer oral valsartan
SCIENCE
HEALTH SCIENCE
NURSING

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