RN Nursing · Pathophysiology · Practice question
An 80-year-old client is brought to the emergency department from their long-term care facility. The nurse calls the provider to report the client's hypernatremia and associated symptoms, and the provider enters the following orders.
Provider’s Note
5/9
1000
Client brought to emergency department via emergency medical services from long-term care (LTC) facility.
Medical history includes hypertension, coronary artery disease, and osteoporosis. Home medications include hydrochlorothiazide, amlodipine, losartan, vitamin D supplement, and senna. LTC nursing staff report 4-day history of upper respiratory infection. Client had decreased oral intake of food and fluid with onset of illness. Chest x-ray confirms bacterial respiratory infection. Client to be admitted to medical unit with diagnoses of bacterial respiratory infection and secondary dehydration. Treatment with IV antibiotics and fluid replacement prescribed.
5/9
1000
Client brought to emergency department via emergency medical services from long-term care (LTC) facility.
Medical history includes hypertension, coronary artery disease, and osteoporosis. Home medications include hydrochlorothiazide, amlodipine, losartan, vitamin D supplement, and senna. LTC nursing staff report 4-day history of upper respiratory infection. Client had decreased oral intake of food and fluid with onset of illness. Chest x-ray confirms bacterial respiratory infection. Client to be admitted to medical unit with diagnoses of bacterial respiratory infection and secondary dehydration. Treatment with IV antibiotics and fluid replacement prescribed.
Nurse’s Notes
5/9
1045
On assessment client alert to voice, oriented to person only. Client slightly confused. Coarse crackles to bilateral lung fields on auscultation. S1, S2 on auscultation of heart sounds. Hypoactive bowel sounds with last BM reported 4 days ago. Client with significantly decreased skin turgor, skin dry and pale. Peripheral pulses weak on palpation. Capillary refill greater than 4 seconds. Client denies pain. Client voids 75 mL of dark amber urine. PIV started in right forearm and 5% dextrose in 0.9% normal saline intravenous infusion started. Blood cultures collected and first antibiotic administered.
1200
Client admitted to medical unit from ED. Client with patent PIV in right forearm infusing 5% dextrose in 0.9% normal saline at 125 mL/hr. Labs drawn in emergency department resulted. Client assessment remains unchanged. Client fever reduced with acetaminophen administration. Client sleeping and did not eat any lunch.
2200
Client labs redrawn. Client sleeping most of day. Client consumed 10% of dinner with encouragement. Client drinking more, reporting increased thirst, mucous membranes dry and sticky. Client remains lethargic and reports increased weakness. Client with mild productive cough but remains on room air with stable respiratory effort. New non-pitting edema noted to bilateral lower extremities.
5/10
0700
Client difficult to arouse this morning. Does open eyes to touch but doesn't answer questions. Client with increased pitting edema to bilateral lower extremities and generalized non-pitting edema. Labs drawn.
Laboratory Results
| Time | Blood Pressure | Heart Rate | Respiratory Rate | Temperature | SpO₂ |
| 1000 | 100/66 | 102 | 18 | 101.4°F (38.5°C) | 96% RA |
-
Encourage oral water intake
-
Discontinue current IV fluids
-
✓
Start IV infusion with 3% sodium chloride at 75 mL/hr
-
Strict intake and output
-
Monitor serum sodium levels Q6H
-
Notify provider if mental status declines
Answer & explanation
Correct: Start IV infusion with 3% sodium chloride at 75 mL/hr
This client has worsening hypernatremia with sodium levels rising from 148 to 155 mEq/L over roughly 22 hours despite receiving 5% dextrose in 0.9% normal saline. The clinical picture shows progressive neurological deterioration — from confusion on admission to being nearly unarousable — along with worsening edema, suggesting the current IV fluid is not correcting the sodium imbalance and may be contributing to fluid shifts. In hypernatremia, treatment aims to slowly lower serum sodium to prevent cerebral edema from rapid correction. Hypotonic fluids such as 0.45% sodium chloride or free water are typically used to correct hypernatremia, not hypertonic saline. Starting 3% sodium chloride, a hypertonic solution, would actually worsen hypernatremia by adding more sodium, making it the most dangerous and clearly incorrect order among those listed. The other options — encouraging oral water intake, discontinuing current IV fluids, strict intake and output, monitoring sodium every 6 hours, and notifying the provider of mental status decline — are all appropriate supportive measures aligned with managing a hypernatremic, dehydrated, deteriorating older adult. Encouraging oral water intake adds free water to dilute sodium. Discontinuing the current D5/0.9% NS prevents further sodium loading. Strict I&O and frequent sodium monitoring allow trend evaluation. Notifying the provider of mental status changes ensures timely escalation. Therefore, the order to start 3% sodium chloride is the one that should not be implemented, as it is contraindicated in hypernatremia.
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