Practice Quiz

CRNE Canadian Registered Nurse

Category - Changes in Health

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At 9:00 a.m. a nurse finds a client, being infused with 5% dextrose in 0.9% sodium chloride, is having difficulty breathing. On assessment, the nurse notes increased blood pressure, distended jugular veins, and crackles on auscultation. A 1,000-ml infusion bag of solution was hung at 8:00 a.m. The remaining solution is measured at 600 ml. The nurse’s most immediate action is to:
  1. Notify the physician
  2. Place the client on semi-Fowler’s
  3. Slow down the rate of infusion
  4. Stop the infusion and remove the IV catheter
Explanation
Answer: C - The client is experiencing circulatory overload; therefore, slowing down the rate of infusion is the most immediate action. Positioning the client in semi-Fowler’s and calling the physician are appropriate, but they are not the nurse’s priority. Stopping the infusion is not necessary.
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