Factors Affecting Body Fluid, Electrolyte Fluid Imbalances
Factors Affecting Body Fluid, Electrolyte Fluid Imbalances ( 5 Questions)
A client who has fluid volume deficit is receiving IV fluids. The nurse notices that the client has crackles in the lungs, dyspnea, and increased blood pressure. Which of the following actions should the nurse take first?
Slow down the infusion rate. This is the correct answer because the client is showing signs of fluid volume overload, which can result from rapid or excessive infusion of IV fluids. Slowing down the infusion rate can help prevent further fluid accumulation in the lungs and reduce the risk of pulmonary edema, which can impair gas exchange and cause respiratory distress.
Check the client's weight. This is not the correct answer because checking the client's weight is not a priority action in this situation. Although weight changes can reflect fluid balance, they are not an immediate indicator of fluid overload or deficit. The nurse should check the client's weight daily at the same time, but not before addressing the acute respiratory symptoms.
Notify the provider. This is not the correct answer because notifying the provider is not the first action that the nurse should take. The nurse should first implement independent nursing interventions to stabilize the client's condition, such as slowing down the infusion rate, elevating the head of the bed, and administering oxygen as needed. The nurse should notify the provider after assessing the client and intervening appropriately.
Raise the client's legs. This is not the correct answer because raising the client's legs can worsen fluid overload by increasing venous return to the heart and lungs. The nurse should avoid this position for clients who have crackles in the lungs, dyspnea, and increased blood pressure, as these are signs of fluid volume excess.
Choice A reason: Slow down the infusion rate. This is the correct answer because the client is showing signs of fluid volume overload, which can result from rapid or excessive infusion of IV fluids. Slowing down the infusion rate can help prevent further fluid accumulation in the lungs and reduce the risk of pulmonary edema, which can impair gas exchange and cause respiratory distress.
Choice B reason:
Check the client's weight. This is not the correct answer because checking the client's weight is not a priority action in this situation. Although weight changes can reflect fluid balance, they are not an immediate indicator of fluid overload or deficit. The nurse should check the client's weight daily at the same time, but not before addressing the acute respiratory symptoms.
Choice C reason:
Notify the provider. This is not the correct answer because notifying the provider is not the first action that the nurse should take. The nurse should first implement independent nursing interventions to stabilize the client's condition, such as slowing down the infusion rate, elevating the head of the bed, and administering oxygen as needed. The nurse should notify the provider after assessing the client and intervening appropriately.
Choice D reason:
Raise the client's legs. This is not the correct answer because raising the client's legs can worsen fluid overload by increasing venous return to the heart and lungs. The nurse should avoid this position for clients who have crackles in the lungs, dyspnea, and increased blood pressure, as these are signs of fluid volume excess.