A 72-year-old male patient with dehydration caused by an exacerbation of ulcerative colitis is receiving 5% dextrose in normal saline at 125 mL/hour. Which assessment finding by the nurse is most important to report to the health care provider?
a. Patient has not voided for the last 4 hours.
b. Skin is dry with poor turgor on all extremities.
c. Crackles are heard halfway up the posterior chest.
d. Patient has had 5 loose stools over the last 6 hours.
c. Crackles are heard halfway up the posterior chest.
The presence of crackles in an older patient receiving IV fluids at a high rate suggests volume overload and a need to reduce the rate of the IV infusion. The other data will also be reported, but are consistent with the patient's age and diagnosis and do not require a change in the prescribed treatment.
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