Author Question: The patient is on daily weights and is receiving intravenous therapy. The nurse notices that the ... (Read 85 times)

Evvie72 · **on:** Jun 25, 2018

The patient is on daily weights and is receiving intravenous therapy. The nurse notices that the patient has gained 2 kg since the previous morning. What else would the nurse expect to observe? (Select all that apply.)

a. Dry skin and mucous membranes
b. Distended neck veins
c. Tenting of the skin
d. Crackles or rhonchi in the lungs

Question 2

The nurse assigns nursing assistive personnel (NAP) to care for several patients with continuous IV infusions. Which of the following can NAP assist with?

a. Changing empty IV solution containers
b. Confirming the correct IV drip rate
c. Assessing the patient for response to IV therapy
d. Informing the nurse if they notice anything abnormal

vseab · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

B, D
A change in body weight of 1 kg corresponds to 1 L of fluid retention or loss. Dry skin and mucous membranes suggest fluid volume deficit (FVD). Distended neck veins suggest fluid volume excess (FVE). Poor skin turgor is seen when after pinching, the skin fails to return to normal position within 3 seconds. With FVD, the pinched skin stays elevated for several seconds. This is called tenting. Auscultation of crackles or rhonchi in the lungs may signal fluid buildup in the lungs caused by FVE.

Answer to Question 2

D
If UAP notice anything they consider abnormal, they should notify the nurse. It is the nurse's responsibility to inform the UAP of specific things to look for. Changing empty IV solution containers cannot be delegated to UAP because the procedure requires knowledge of sterile technique. Confirming the correct IV drip rate is the nurse's responsibility. Assessment is not the responsibility of UAP; it is the responsibility of the nurse.