The nurse is caring for a client who has SIADH. The nurse notices that the client has become confused and extremely short of breath, and crackles are heard when lungs are auscultated. What is the first action by the nurse?
A) Administer a diuretic.
B) Notify the physician.
C) Lay the client flat.
D) Suction the client.
B
Feedback:
The nurse closely monitors fluid intake and output and vital signs. He or she carefully assesses LOC and immediately reports any changes to the physician. The nurse checks closely for signs of fluid overload (confusion, dyspnea, pulmonary congestion, hypertension) and hyponatremia (weakness, muscle cramps, anorexia, nausea, diarrhea, irritability, headache, weight gain without edema). Laying the client flat would increase the shortness of breath and would deoxygenate the client. The nurse cannot administer a diuretic without the physician's order. Suctioning of the client will not clear the airway at this time.
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