At 9:00 a.m., a nurse finds that a client being infused with 5% dextrose in 0.9% sodium chloride is having difficulty of breathing. On assessment, the nurse notes increased blood pressure, distended jugular veins, and crackles on auscultation. The solution in a 1,000 ml infusion bag was hung at 8:00 a.m. The remaining solution is measured at 600 ml. The nurse's most immediate action is to:
A)Notify the physician
B)Place the client in semi-Fowler's
C)Stop the infusion and contact the physician
D)Stop the infusion and remove the IV catheter

Question

Quizplus · Accepted Answer

The client is experiencing circulatory overload; therefore, stopping the infusion until the physician is notified is the best immediate action. Positioning the client in semi-Fowler's is appropriate, but stopping the infusion should be done first.

At 9:00 AM