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 re-evaluation of the IV therapy prescription?

A) Swelling and tenderness at the IV site
B) Blood pressure within normal limits
C) Urine output of 30 mL/hour
D) Heart rate of 80 beats per minute

Answer 1

Swelling and tenderness at the IV site should alert the nurse that the IV therapy prescription needs to be re-evaluated, as it may indicate infiltration or infection.

Step-by-step explanation:

The information in the client's medical record that should indicate to the nurse that the client requires a re-evaluation of the IV therapy prescription is A) Swelling and tenderness at the IV site. This could suggest an infiltration or infection at the IV site, which might lead to complications and therefore needs immediate attention. Blood pressure within normal limits, urine output of 30 mL/hour, and a heart rate of 80 beats per minute are generally considered within normal ranges and would not typically signal an immediate concern for re-evaluating the IV therapy prescription unless they represented a significant change from the patient's baseline.