The nurse is assessing a client being treated with 3% normal saline solution. Which assessment finding should be reported to the health care provider immediately?
1. Temperature of 100.1°F
2. Blood pressure of 146/92
3. Presence of auscultated crackles
4. Presence of auscultated rhonchi
Correct Answer: 3
Rationale 1: Although above normal limits, a temperature of 100.1°F does not put a client in immediate danger.
Rationale 2: Blood pressure of 146/92 does not put a client in immediate danger.
Rationale 3: Crackles are a sign of pulmonary edema, which can occur with the use of 3% normal saline solution. This assessment finding should be reported to the health care provider immediately.
Rationale 4: Rhonchi are generally auscultated in clients with inflammation of the large airway. This is not consistent with the use of 3% normal saline solution.
Global Rationale: Crackles are a sign of pulmonary edema, which can occur with the use of 3% normal saline solution. This assessment finding should be reported to the health care provider immediately. Although above normal limits, a temperature of 100.1°F does not put a client in immediate danger. Blood pressure of 146/92 does not put a client in immediate danger. Rhonchi are generally auscultated in clients with inflammation of the large airway. This is not consistent with the use of 3% normal saline solution.
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