The nurse hears in report that a client receiving parenteral nutrition (PN) at 100 mL/hr has...

The nurse hears in report that a client receiving parenteral nutrition (PN) at 100 mL/hr has bilateral crackles and 1+ pedal edema. When the nurse obtains a daily weight, the nurse notes that the client has gained 4 lb in 2 days. Which of the following nursing actions should the nurse take first? Must pick which answer they think is correct and then also state why the others are wrong.

	1. Encourage the client to cough and deep-breathe. 2. Compare the intake and output records of the last 2 days. 3. Slow the PN infusion rate to 50ml/hr per infusion pump. 4. Administer the prescribed daily diuretic and check the patient in 2 hours.

Expert Solution

Option a is wrong as the patientis having symptoms of hypervolemia and this might be due to excess fluid intake or retention. So just by coughing and deep breathing exercise no much effect or improvements will occur so it is wrong .

Option b is correct as checking the intake and output chart of the patient Will give the exact reason for the condition of the patient and only if the exact reason is know interventions can be initiated. It can be due to excess fluid intake due to increase in parentral nutrition or it can be due to fluid retention in the patient. This retention can be due to conditions like renal failure to rule this out and to find and exact reason we have to review the intake and output and this will be the first step that nurse will do .

Option c is wrong as slowing of the infusion pumb rate requires the physician order as well as it might lead to conplications like hypoglcemia in the patient . So only afterreviewing the I/O and finding the reason then only changes should be made .

Option d is wrong as the condition of the patient requires immediate action and it is not possible if we administer diuretics . It will take upto 2hrs for the regular diuretics to give results . Only after ruling out if it is due to increased intake of fluid or due to fluid retention and then only the interventions can be initiated. As the exact cause should be treated .

Nightingale answered 2 years ago

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