Get Answer: Nurse Reviews Medical Question Guide
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Original Question
The nurse reviews the medical record of a 54-year-old client admitted with a blood alcohol concentration (BAC) of 0.24% (serum ethanol level of 240 mg/dL (52.1 mmol/L]). Relaunch to ur Nurses* Flow Shee Physician’s Orders Lab Test: Notes 0330: Admitted to ED accompanied by children who state the client has been drinking every night since the spouse died last year from breast cancer. Medical history includes Stage 2 chronic kidney disease and hypertension. Client disoriented, has an ataxic gait, and is extremely drowsy. Speech slurred; irritable and disoriented. IV of 5% D/0.45 NS initiated 0430: Very drowsy, disoriented, increasingly irritable with slight hand tremors. Vomited 100 mL clear greenish yellow liquid. 0530: Becoming more agitated and yelling at staff. Disoriented and drowsy, speech continues to be slurred. Hand tremors worsening. Vomited 75 mL clear greenish liquid; obtained order for ondansetron and administered x 1. Has not voided since admission. Nurses Notes Vital Signs T (forehead) HR RR BP Flow Sheet Physician’s Orders Lab Tests 0330 (Admission) 0430 0530 96.8° F (36° C) 96.8° F (36° C) 97.2° F (36.2° C) 62 BPM 64 BPM 64 BPM 14 bpm 14 bpm 16 bpm 100/58 mmHg 102/54 mmHg 106/58 mmHg Complete the following sentence by selecting from the lists of options below. The priority nursing action is to monitor the cllent for – and which are commonly associated with
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