The nurse hears in intershift 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? 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 50 mL/hr per infusion pump.
4. Administer the prescribed daily diuretic, and check the client in 2 hours.
2
Rationale: The client is showing signs of fluid retention and possible excess fluid intake, as not-ed by the presence of crackles, edema, and weight gain. Noting the client's intake and output records adds to the database of information, which should then be reported. The problem may or may not be related to the PN. (Other possible causes are impaired respiratory, cardiovascular, or renal function.)
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