When administering hypertonic saline to the patient with increased intracranial pressure (ICP), the nurse would: Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply
1. Monitor the patient for renal failure and pulmonary edema.
2. Administer any concentrations greater than 2% through a central line.
3. Monitor serum sodium levels frequently during administration.
4. Expect the patient's neurologic status and ICP will begin to improve within 15 minutes following administration.
5. Monitor the patient's serum osmolarity every 24 hours.
1,2,3,4
Rationale 1: Renal failure and pulmonary edema can occur from this fluid.
Rationale 2: A solution greater than 2% should be administered through a central line.
Rationale 3: Serum sodium levels should be frequently monitored during the administration of this fluid.
Rationale 4: The patient's neurologic status and intracranial pressure level will improve within 15 minutes following the administration of this fluid.
Rationale 5: Serum osmolarity should be measured at least every 12 hours and maintained at less than 320 mOsm/L.
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