[Verified Answer]: GROUP “B”- Case Study A 69-year-old client…

GROUP “B”- Case Study A 69-year-old client presents to the emergency department reporting fatigue, muscle aches, weakness. and severe cramping for 2 days. He reports being ill recently with nausea, vomiting and diarrhea that lasted 3 days. The client has a history of rheumatic fever, congestive heart failure (CHF) and hypertension. The client states that he follows a low-sodium diet, weighs himself daily and has continued this regiment throughout the current illness. The client has no known allergies and his current medication list includes: Metoprolol succinate 100 mg daily Lisinopril 5 mg daily Digoxin 0.25 mg daily Aspirin 81 mg daily K-Lor 20 mEq daily Furosemide 40 mg daily Nursing Assessment: 1. Alert, oriented to person, place, and time 2. Heart sounds S1 and S2 present but irregular, no murmur 3. Orthostatic hypotension 4. Pedal and radial pulses irregular, 1+, and weak bilaterally 5. Deep tendon reflexes 1+, and weak bilaterally 6. Bowel sounds hypoactive in all 4 quadrants 7. Chest x-ray: cardiomegaly; no evidence of CHF 8. ECG: sinus tachycardia, occasional to frequent PVCs, depressed ST segment Vital Signs Laboratory Results Current weight: 135 lb Serum K+ 2.7 mEq/L Temperature: 97.8° F orally Serum Na 140 mEq/L B/P: 115/65 supine Blood glucose 80 mg/dl 106/58 sitting Serum BUN 30 mg/dL 92/54 standing Serum creatinine 1.3 mg/dL Heart rate: 112 bpm, irregular Digoxin level 2.3 ng/mL (normal Respiratory rate: 20 0.5 to 2 ng/mL) O2 saturation: 96% Health Care Provider Prescription 1. Place on telemetry 2. Fall precautions 3. Vital signs every 15 minutes x 1 hour and then every 30 minutes x 1 hour, then every 4 hours if stable 4. Monitor intake and output 5. Administer IV solution now; 40 mEq of potassium chloride diluted in 500 mL of normal saline solution at 10 mEq/hr 6. Hold digoxin, metoprolol and lisinopril 7. Clear liquid diet 8. Repeat ECG, serum potassium, glucose, and electrolytes in 4 hours and notify HCP of results 9. Refer to primary HCP to restart digoxin and adjust potassium chloride, furosemide, metoprolol and lisinopril dosages Peer Post B” The oncoming nurse notes that D5 and 0.9% NS is infusing with approximately 1⁄2 of a liter bag infused. After changing to the correct fluid, what would be the priority assessments?