NCLEX-RNSafety and Infection Prevention and ControlMedium
A nurse is caring for a client who is receiving intravenous fluids and suddenly develops signs of fluid overload (e.g., dyspnea, crackles in lungs, peripheral edema). What is the nurse's priority action?
- ANotify the healthcare provider.
- BAdminister a prescribed diuretic medication.
- CElevate the head of the client's bed.
- DDecrease the rate of the intravenous fluid infusion.
Show answer & explanationAnswer & explanation
Correct answer: D. Decrease the rate of the intravenous fluid infusion.
When a client receiving IV fluids shows signs of fluid overload, the most immediate and direct intervention to stop the progression of the overload is to decrease or stop the intravenous fluid infusion. This directly addresses the cause of the overload, which is the ongoing administration of fluids. Other actions, while important, are secondary or require an order.
Why the other options are wrong
- A. Notifying the provider is essential, but a direct intervention to address the immediate physiological problem should be performed first.
- B. Administering a diuretic requires a physician's order, and the immediate action should be to stop the fluid source if possible.
- C. Elevating the head of the bed will help ease breathing but does not address the underlying cause of the fluid overload.
Fluid Overload Management
Interventions to reduce excess fluid volume in the body, typically characterized by respiratory and cardiovascular symptoms.
- Prioritize stopping fluid intake.
- Assess respiratory status.
- Administer diuretics as prescribed.
Memory trick: When Fluids Rise, Slow the Drip, Save their Lives.