Practice Quiz

Vascular Access Exam Prep

Category - Vascular Access Practice Test

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At 9:00 a.m., a nurse finds that a client being infused with 5% dextrose in 0.9% sodium chloride is having difficulty of breathing. On assessment, the nurse notes increased blood pressure, distended jugular veins, and crackles on auscultation. The solution in a 1,000 ml infusion bag 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 in semi-Fowler’s
  3. Stop the infusion and contact the physician
  4. Stop the infusion and remove the IV catheter
Explanation
Answer: C - The client is experiencing circulatory overload; therefore, stopping the infusion until the physician is notified is the best immediate action. Positioning the client in semi-Fowler’s is appropriate, but stopping the infusion should be done first.
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