Medical Surgical Fluids and Hormones #1

Question

A client recovering from an exploratory laparotomy and the removal of a large intestinal tumor has a nasogastric tube (NGT) in place and intravenous (IV) fluid infusion at 150 mL/hr via a pump. Which data should the nurse report to the health care provider?

Answers

  1. The IV pump sounds an alarm that the high pressure has been reached.
    • Rationale:

      This answer is not correct because the healthcare provider would not be notified for malfunctioning equipment. The nurse should report crackles present in all lung fields to the HCP as this finding is abnormal and requires further evaluation.

  2. Intake is 1800 mL, NGT output is 550 mL, and urine output 950 mL.
    • Rationale:

      This answer is not correct because the client’s intake and output is not unusual.The nurse should report crackles present in all lung fields to the HCP as this finding is abnormal and requires further evaluation.

  3. Crackles are present in all lung fields.
    • Rationale:

      This answer is correct because crackles in the lungs can indicate pneumonia, atelectasis, pulmonary fibrosis, acute bronchitis, bronchiectasis, acute respiratory distress syndrome (ARDS), interstitial lung disease, post-thoracotomy, or metastasis ablation.

  4. White blood cell count (WBC) is 9.0.
    • Rationale:

      This answer is not correct because the WBC is within normal limits. The nurse should report crackles present in all lung fields to the HCP as this finding is abnormal and requires further evaluation.

Overview

The nursing process includes assessment, diagnosis, planning, implementation, and evaluation. The nurse should report crackles present in all lung fields to the health care provider as this finding is abnormal and requires further evaluation.

Explanation

Learning Outcomes

Nursing assessment is used to identify current and future client care needs. It incorporates the recognition of both normal, and abnormal, body physiology. The nurse must report abnormal physiologic findings to the healthcare provider (HCP) to decrease the likelihood of complications. Therefore, the nurse reports crackles present in all lung fields to the HCP as this finding is abnormal and requires further evaluation.

Test Taking Tip

Determine which finding is abnormal and requires further intervention from the HCP to answer this question correctly.

Video Rationale