Question

23 of 50 a client has been receiving total parenteral nutrition at 125 ml/hr for 5 days. on assessment, the nurse notes bilateral crackles and 2+ pedal edema and that the client has gained 3 pounds in 5 days. which would be appropriate as the initial nursing action? answer - options 1 notify the registered nurse of the findings 2 encourage the client to cough and deep breathe 3 check the clients medication prescriptions for a diuretic 4 slow the parenteral nutrition infusion rate to 100 ml/hr

Explanation:

The client shows signs of fluid - volume excess (bilateral crackles, pedal edema, weight gain) during total parenteral nutrition. The initial nursing action should be to notify the registered nurse as this is a significant clinical finding that requires immediate attention and further assessment/management by a more experienced nurse or the healthcare team. Encouraging coughing and deep - breathing is not the priority for fluid overload, checking for a diuretic prescription is a later step after notifying the RN, and adjusting the infusion rate without proper assessment and orders is inappropriate.

Answer:

1. Notify the registered nurse of the findings.