At 9:00 a.m. a nurse finds a client, being infused with 5% dextrose in 0.9% sodium chloride, is having difficulty breathing. On assessment, the nurse notes increased blood pressure, distended jugular veins, and crackles on auscultation. A 1,000-ml infusion bag of solution 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 on semi-Fowler's
C)Slow down the rate of infusion
D)Stop the infusion and remove the IV catheter

Question

Quizplus · Accepted Answer

The client is experiencing circulatory overload; therefore, slowing down the rate of infusion is the most immediate action. Positioning the client in semi-Fowler's and calling the physician are appropriate, but they are not the nurse's priority. Stopping the infusion is not necessary.

At 9:00 AM