Question

A nurse on a medical-surgical unit is reviewing the medical record of an older adult client who is receiving IV fluid therapy. Which of the following client information should indicate to the nurse that the client requires reevaluation of the IV therapy prescription?

A) Blood pressure decreased from 130/80 to 120/70 mm Hg.

B) Urine output has increased from 30 ml/hr to 50 ml/hr.

C) Crackles are audible on lung auscultation.

D) Weight has increased by 2 pounds over the last 24 hours.

Answer 1

Crackles on lung auscultation and a weight increase of 2 pounds over 24 hours should prompt a nurse to reevaluate a client's IV fluid therapy prescription, as they may indicate fluid overload or pulmonary edema.

Step-by-step explanation:

When reviewing the medical record of an older adult client receiving IV fluid therapy, a nurse should be alerted by audible crackles on lung auscultation. This finding could indicate the development of fluid overload or pulmonary edema, conditions where the lungs fill with fluid, impairing respiratory function. An increase in weight of 2 pounds over the last 24 hours may also support this concern, as it can reflect fluid retention. Although changes in blood pressure and urine output are significant, these specific changes do not necessarily indicate an immediate need for reevaluation unless other symptoms are present.