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Vascular Access Exam Prep

Category - Vascular Access Practice Test

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A nurse is making the initial rounds for the IV fluids of clients assigned to her care. The nurse notes that the client in Room 312, a 23-year-old student admitted for hemorrhagic fever, is complaining of difficulty breathing with productive cough. The nursing assessment shows swelling of the arms and crackles. How should the nurse have prevented this?
  1. Elevate the head of bed.
  2. Closely monitor oral fluid intake.
  3. Use infusion pumps to reduce the risk of rapid fluid infusion.
  4. Monitor daily weights and I&O to appropriately adjust the IV infusion.
Explanation
Answer: C - To prevent fluid volume overload, the nurse should use infusion pumps as much as possible to prevent rapid fluid infusion. Rapid IV infusion results in heart congestion and pulmonary edema. To manage fluid volume overload, the client is placed in an upright position to promote ventilation. Oral fluid intake rarely causes congestion, and if it does, it does so gradually. Daily weights are done to monitor changes in fluid status.
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