The client who has undergone an exploratory laparotomy and subsequent removal of a large intestinal tumor has a nasogastric tube (NGT) in place and an IV running at 150 mL/HR via an IV pump. Which data should be reported to the health care provider?
A. The pump keeps sounding an alarm that the high pressure has been reached. B. Intake is 1800 mL, NGT output is 550 mL, and Foley output 950 mL. C. On auscultation, crackles and rales in all lung fields are noted. D. Client has negative pedal edema and an increasing level of consciousness.
On auscultation, crackles and rales in all lung fields are noted.-a. (incorrect) the pump is alerting the nurse that there is resistance distal to the pump; this does not require notifying the health care provider.b. (incorrect) the client has an 1800 ml intake and total output of 1500 ml. the body has an insensible loss of approximately 400 ml per day through the skin, respirations, and other body functions. this would not warrant notifying the health care provider.c. (correct) crackles and rales in all lung fields indicate that the body is not able to process the amounts of fluids being infused. this should be brought to the health care providers attention.d. (incorrect) negative pedal edema and an increasing level of consciousness indicate that the client is not experiencing a problem.test-taking hint: the question requires the test taker to distinguish nursing problems from client problems. option a is a nursing problem and options b and d are expected results, so the health care provider does not need to be notified. only one option, c, contains abnormal or life-threatening information.