A client with heart failure has been receiving an I.V. infusion at 125 ml/hour. Now the client is short of breath and the nurse notes bilateral crackles, neck vein distention, and tachycardia.
What should nurse Sharon do first?
- a. Notify the physician
- b. Discontinue the infusion
- c. Administer a prescribed diuretic
- d. Slow the infusion and notify the physician
Answer D.
Because this client has fluid overload, the nurse first should slow the infusion to prevent additional fluid overload, and then notify the physician and obtain further orders.Notifying the physician without slowing the infusion would put the client at risk for pulmonary complications or respiratory failure. Discontinuing the infusion is inappropriate because vascular access still may be needed to administer I.V. fluids (at a decreased rate) or additional I.V. medications. Administering a diuretic without changing the I.V. infusion rate wouldn’t prevent fluid overload from recurring.
slow the infusio:
Yes, the nurse should slow the infusion and notify the physician if a client with heart failure who has been receiving an IV infusion at 125 ml/hour is now short of breath and the nurse notes bilateral crackles, neck vein distention, and tachycardia. These are all signs and symptoms of fluid overload, which is a serious complication of heart failure.
reduce the amount of fluid:
Fluid overload occurs when the body is unable to keep up with the demand to excrete fluids. This can lead to a buildup of fluid in the lungs, which can make it difficult to breathe. Fluid overload can also cause swelling in the feet, ankles, and abdomen.
The nurse should slow the infusion immediately to reduce the amount of fluid entering the client's body. The nurse should also notify the physician so that they can assess the client's condition and determine the best course of treatment.
excrete fluids:
In addition to slowing the infusion, the physician may also order medications to help the client excrete fluids, such as diuretics. The physician may also need to restrict the client's fluid intake.
If the client's fluid overload is severe, the physician may need to admit the client to the hospital for further treatment.
Steps to be taken:
Here is a summary of the steps the nurse should take:
- Slow the infusion immediately.
- Notify the physician.
- Monitor the client's vital signs and breathing closely.
- Position the client in a comfortable position, such as sitting upright.
- Provide the client with supplemental oxygen as needed.
- Encourage the client to cough up any secretions.
- Administer medications as prescribed by the physician.
By taking these steps, the nurse can help to manage the client's fluid overload and prevent serious complications.
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Psychosocial Integrity