Data collection findings for a patient include shortness of breath with crackles in the lung bases, jugular vein distention, daily weight increased by 3 pounds from yesterday, report of chest pain, blood pressure 86/40 mm Hg, pulse 132 beats/minute, and respirations 30/minute. Which of these orders should the nurse question?

Question

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The patient is showing signs of heart failure (e.g., jugular vein distention, crackles in the lung bases, rapid weight gain) and possibly cardiogenic shock (e.g., low blood pressure, high pulse rate). Administering 500 mL of 0.9% normal saline (NS) over 30 minutes could exacerbate fluid overload, worsening the patient's condition. The other orders (A, C, D) are appropriate for assessing and managing the patient's condition.

Data Collection Findings for a Patient Include Shortness of Breath