[Case Study 1, Screen 2: 1000 nurses' notes, vital signs, prescriptions, and IV access.] Which action should the nurse take?

CLIENT
63-year-old woman. Weight 70 kg.
History: type 2 diabetes (takes metformin), hypertension (takes lisinopril).
Lives with spouse; independent in all activities; baseline fully oriented.
Home blood pressure readings usually about 132/78 mm Hg.

NURSES' NOTES - 0800
Spouse reports the client has been "sleepy and confused" since last night.
Client reports burning on urination for 3 days and has been eating and
drinking very little for 2 days. Oriented to person only. Skin warm and
flushed; mucous membranes dry. Reports right flank pain, 5/10. Lungs clear
bilaterally. Capillary refill 3 seconds. Last voided a small amount of dark
urine early this morning.

VITAL SIGNS - 0800
Temperature      39.0°C (102.2°F)
Heart rate       116/min
Respiratory rate 24/min
Blood pressure   88/50 mm Hg (MAP 63 mm Hg)
SpO2             95% on room air

LABORATORY RESULTS - 0815            Result            Reference range
WBC                                  18,600/mm³        5,000-10,000/mm³
  Bands                              14%               0-5%
Lactate                              4.1 mmol/L        0.5-2.0 mmol/L
Creatinine                           1.9 mg/dL         0.5-1.1 mg/dL
  (baseline 1 month ago: 0.9 mg/dL)
BUN                                  40 mg/dL          7-20 mg/dL
Glucose (random)                     238 mg/dL         70-140 mg/dL
Sodium                               137 mEq/L         135-145 mEq/L
Potassium                            4.6 mEq/L         3.5-5.0 mEq/L
Platelets                            172,000/mm³       150,000-400,000/mm³
Urinalysis: cloudy; nitrite positive; leukocyte esterase positive;
            WBC more than 50/hpf


NURSES' NOTES - 1000
Blood cultures x2 drawn at 0820. Piperacillin-tazobactam IV started at 0835.
Lactated Ringer's solution 2,100 mL IV completed at 0955. Client is lethargic
but arousable. Extremities cool. Indwelling urinary catheter inserted at 0830;
25 mL of urine since insertion.

VITAL SIGNS - 1000
Temperature      38.6°C (101.5°F)
Heart rate       124/min
Respiratory rate 26/min
Blood pressure   80/44 mm Hg (MAP 56 mm Hg)
SpO2             94% on room air

PROVIDER PRESCRIPTIONS - 1000
- Norepinephrine continuous IV infusion; titrate to maintain MAP at or
  above 65 mm Hg.
- Central venous catheter insertion when the provider is available
  (estimated 1 to 2 hours).

IV ACCESS
- 18-gauge peripheral IV, right upper forearm (proximal, below the elbow
  crease): patent, no redness or swelling.
- 20-gauge peripheral IV, dorsum of left hand: patent.

1. AHold the norepinephrine until the central venous catheter has been inserted.
2. BStart the norepinephrine through the 18-gauge right proximal forearm IV and monitor the site closely.
3. CStart the norepinephrine through the 20-gauge left hand IV so the forearm line remains available for other infusions.
4. DInfuse another 2,000 mL of lactated Ringer's solution and hold the norepinephrine until it is complete.