As part of the report, the nurse of the medical surgical unit was told that the client's Foley catheter had been empty prior to leaving the PACU/recovery room. Two hours later, the nurse notes that the client's output is 30 mL
What is the nurse's best first action? A. Measure and compare total output with total intake.
B. Document the finding as the only action.
C. Increase the rate of IV fluids by 50 mL/hour.
D. Notify the surgeon immediately.
A
Fluid balance is affected by a variety of factors, including length of fasting before surgery, fluid loss during the surgical procedure, and the amount of fluids or blood given during surgery. Post-operatively, intake (IV fluid, oral intake) must be measured against output from insensible fluid loss, diaphoresis, wound drainage, or drainage in tubes such as an NG tube or Jackson-Pratt drain. Once this information is gathered concerning the client's total intake and output, the nurse determines whether to call the physician.
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A nurse is caring for an infant with neonatal abstinence syndrome. Which manifestation should the nurse expect to assess?
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