NCLEX-RNSafety and Infection Prevention and ControlMedium
The nurse is caring for a client who is receiving intravenous fluids and suddenly develops shortness of breath, crackles in the lungs, and distended neck veins. The nurse suspects fluid overload. Which action should the nurse take FIRST?
- AAdminister a prescribed diuretic.
- BDecrease the rate of the intravenous fluid infusion.
- CNotify the healthcare provider.
- DElevate the head of the client's bed.
Show answer & explanationAnswer & explanation
Correct answer: B. Decrease the rate of the intravenous fluid infusion.
In an acute situation of suspected fluid overload, decreasing the rate of the IV fluid infusion immediately reduces the amount of fluid entering the client's circulatory system, preventing further worsening of symptoms while other interventions are initiated. This is a direct intervention to address the cause.
Why the other options are wrong
- A. Administering a diuretic requires a prescription and takes time to act; reducing the IV rate is a more immediate nursing intervention.
- C. Notifying the healthcare provider is crucial, but a direct nursing intervention to stabilize the client should occur first to prevent further deterioration.
- D. Elevating the head of the bed helps with breathing but does not address the underlying cause of the fluid overload.
Fluid Overload (Hypervolemia) Management
Interventions aimed at reducing excess fluid volume in the body, often due to excessive IV fluid administration, heart failure, or renal dysfunction.
- Signs include dyspnea, crackles, peripheral edema, distended neck veins, increased blood pressure.
- Immediate nursing actions include slowing/stopping IV fluids and elevating the head of the bed.
- Diuretics and oxygen therapy may be prescribed by the provider.
Memory trick: STOP the FLOW, then HELP them BREATHE, then CALL for aid.