The patient is on intake and output (I&O) as well as daily weights. The nurse notes that output is considerably less than intake over the last shift, and daily weight is 1 kg more than yesterday. The nurse should:
a. draw a trough level after the next dose of antibiotic.
b. obtain an order to place the patient on fluid restriction.
c. assess the patient's lungs.
d. insert an indwelling catheter.
C
The scenario indicates retention of fluid; therefore, the nurse must assess for symptoms of fluid overload, for example, by auscultating the lung fields. Adequate hydration is essential and fluid restriction would be determined by the physician upon physical examination and analysis of laboratory results. An indwelling urinary catheter should not routinely be inserted because it increases the risk of infection. A trough level is drawn just before the next dose of a drug is given and is an indicator of how the body has cleared the drug; it would not be done secondary to imbalanced intake and output.
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