Data collection findings for a patient include shortness of breath with crackles in the lung bases, jugular vein distention, daily weight increased by 3 pounds from yesterday,
report of chest pain, blood pressure 86/40 mm Hg, pulse 132 beats/minute, and respirations 30/minute. Which of these orders should the nurse question?
a. Electrocardiogram (ECG) STAT
b. 500 mL 0.9% NS over 30 minutes
c. Arterial blood gases (ABGs) STAT and repeat in 1 hour
d. Oxygen 2 L/min via nasal cannula
ANS: B
The patient data indicate possible cardiogenic shock. This means that any fluid given may overwhelm the heart, which could lead to death. So, the nurse should question IV orders for a cardiogenic shock patient. An ECG, ABGs, or oxygen would be appropriate orders.
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