Client Dаtа Nurses' Nоtes — 0730 A 74-yeаr-оld client arrives at the emergency department with the family. The client repоrts increasing shortness of breath over four days and swelling in both legs, and has been sleeping in a recliner for three nights. The client reports taking furosemide (Lasix) daily and states running out about two weeks ago. The family reports the client has been more tired and has been dropping objects. Vital Signs — 0740 Temperature 36.8°C · Heart rate 112 and irregular · Respirations 26 · Blood pressure 158/94 · Oxygen saturation 89% on room air Assessment — 0745 Crackles bilaterally to mid-lung fields. Jugular vein distention present at 45 degrees. 3+ pitting edema to bilateral lower extremities. Bilateral hand grasps weak. Client is oriented to person, place, and time. Weight 92 kilograms; documented weight at clinic visit four weeks ago was 87 kilograms. Laboratory Results — 0815 Sodium 133 mEq/L · Potassium 2.8 mEq/L · Chloride 96 mEq/L · Magnesium 1.3 mEq/L · Calcium 8.9 mg/dL · Blood urea nitrogen 32 mg/dL · Creatinine 1.4 mg/dL · Hemoglobin 11.8 g/dL · Hematocrit 35% · BNP markedly elevated Analyze Cues. For each finding, indicate whether it supports fluid volume excess, hypokalemia, or both.
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