The practical nurse (PN) heard adventitious breath sounds while auscultating the lungs of an older adult who is receiving an IV of 5% dextrose in water (DW) at 100 mL/hour. Which action should the PN take next?
A.
Report the findings to the charge nurse.
B.
Review the last balance of intake and output.
C.
Slow the DSW infusion rate to 50 ml/hour.
D.
Document the findings and monitor the client.
The Correct Answer and Explanation is :
The correct answer is B. Review the last balance of intake and output.
Explanation
When a practical nurse (PN) hears adventitious breath sounds during auscultation in an older adult receiving an intravenous (IV) infusion of 5% dextrose in water (DW) at 100 mL/hour, the next step should be to review the last balance of intake and output. This action helps in determining if the patient has been retaining fluid, which could contribute to the abnormal breath sounds.
Rationale:
- Understanding Adventitious Breath Sounds: Adventitious breath sounds, such as crackles or wheezes, may indicate fluid overload, pulmonary congestion, or other issues. In older adults, these sounds can be particularly significant as they may signal complications related to heart failure or renal impairment.
- Fluid Balance and Implications: Reviewing the intake and output records helps assess whether the patient has accumulated excess fluid, which is a common cause of pulmonary congestion. An imbalance where fluid intake exceeds output could contribute to fluid retention, leading to adventitious breath sounds.
- Why Not Other Options?
- A. Report the findings to the charge nurse: While important, reporting findings is not the immediate next step. It is essential to assess the situation further before escalating it.
- C. Slow the DSW infusion rate to 50 mL/hour: Adjusting the infusion rate might be necessary if fluid overload is confirmed, but it is more prudent to first review the intake and output to confirm whether fluid overload is the cause of the breath sounds.
- D. Document the findings and monitor the client: Documentation and monitoring are necessary but should follow a more detailed assessment. Reviewing the intake and output provides critical information that could direct further actions.
By reviewing the intake and output, the PN can determine whether fluid retention is contributing to the adventitious breath sounds and take appropriate action, such as adjusting the IV infusion rate or notifying the charge nurse if fluid overload is confirmed. This approach ensures that any intervention is based on a thorough understanding of the patient’s fluid status.