An elderly patient receiving an infusion of an isotonic fluid at 100 mL/hr complains of dyspnea.The nurse notes shallow rapid respirations and a cough that produces frothy sputum.Which is the priority nursing action?

Question

Quizplus · Accepted Answer

The priority nursing action is to elevate the head of the bed to decrease venous return and relieve the pressure on the patient's chest. This will aid in improving the patient's breathing and reduce the chance of pulmonary edema. Assessing the urine output (A) is important for overall fluid balance but is not the priority in this situation. Encouraging the patient to cough (C) may actually worsen their symptoms as it may increase their workload of breathing. Maintaining the IV rate (D) should be paused until the patient's symptoms have been evaluated and managed.

An Elderly Patient Receiving an Infusion of an Isotonic Fluid