The nurse is caring for a patient who is at risk for developing cerebral vasospasm. The nurse recognizes which order as inappropriate for this patient?
1. Discontinue IV fluids when tolerating fluids.
2. Monitor serum electrolytes daily.
3. Hold antihypertensive medications.
4. Monitor blood pressure hourly.
1
Rationale 1: Patients with subarachnoid hemorrhage are at significant risk for vasospasm. IV fluids should not be discontinued even if the patient has adequate oral intake.
Rationale 2: Monitoring serum electrolytes, especially sodium, is appropriate.
Rationale 3: Antihypertensive medications should not be administered without parameters for administration.
Rationale 4: Blood pressure should be monitored at least hourly.
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