Client is a 72-year-old male with a recent diagnosis of Deep…

Client is a 72-year-old male with a recent diagnosis of Deep Vein Thrombosis is seen in the Emergency Department.  EMERGENCY DEPARTMENT TRIAGE NOTE: 1520: The client arrives by ambulance to the Emergency Department with difficulty breathing, sharp pain in chest on inspiration and cough (pink-tinged), onset 2 hours prior to arrival. Lung sounds diminished bilaterally. Client diaphoretic, tachypneic, using accessory muscles with inspiration. Vital Signs: BP 162/94, HR122, RR 30, Temp. 99.1 degrees Fahrenheit , pulse oximetry 88% on room air. Client immediately placed in room. Provider called to beside for rapid assessment. Which of the following actions are appropriate and the nurse should implement? Select all that apply.

The nurse cares for a 21 year-old male with a history of HIV…

The nurse cares for a 21 year-old male with a history of HIV admitted the the medical surgical unit with respiratory distress. Nurses’ Note     1100: A 25-year-old male who has been HIV positive for 3 years is admitted for a dry cough and fever of 101.0oF/ 38.3oC. The client has fatigue, shortness of breath, a respiratory rate of 28, and pulse oximeter of 90% on room air. Breathing is slightly labored and he has a tight feeling in the chest when taking a deep breath. He has been on antiretroviral medications since his diagnosis of HIV but recently stopped taking the medication when he was laid off from his job. His symptoms did not improve with over-the-counter medications after 3 days.  IV started in 0.9% normal saline infusing in the right arm at 75 ml/hr. Labs drawn. Laboratory Report     BUN 22 mg/dL 10-20 mg/dL Creatinine (Serum) 1.5 mg/dL 0.9 to 1.4 mg/dL Hematocrit 48 % Males: 42-52%;Females: 35-47% Hemoglobin 15g/dL Males: 13-18 g/dL; Females:12-16 g/dL WBC 15.2 mm3 4.5 – 10.5 x 103 cells/mm3 Platelets 300,000 mm3 140,000 to 450,000/ mm3 PT 10 seconds 9.5-12 seconds CD 4 178 mm3 500- 1,500 cells/mm3 Potassium(serum) 4.5 mEq/L 3.5 to 5 mEq/L Sodium (serum) 148 mEq/L 135 to 145 mEq/L       Which 2 lab findings are most concerning? Select the 2 most concerning lab findings.