A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg. a fluid intake of 960 mL, and an output of 300 mL in the past 12 hr. Which of the following actions should the nurse take?

Slow infusion rate and contact the provider.

Lower the head of the bed to semi-Fowler's.

Administer prescribed corticosteroids.

Change infusion to lactated Ringer's and maintain rate.

Answer and Explanation

The Correct Answer is A

A.   The client's dyspnea and elevated blood pressure may indicate fluid volume overload. Slowing the infusion rate and notifying the provider are appropriate actions.
B.   Lowering the head of the bed may help with dyspnea but does not address the underlying cause of fluid overload.
C.   Administering corticosteroids is not indicated based on the client's symptoms and situation.
D.   Changing the infusion to lactated Ringer's may be appropriate, but slowing the infusion rate and assessing the client further are the priority actions.

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Correct Answer is ["A","B","C","D","E","F","G","H","I","J"]

Explanation

The client's condition shows signs of improvement as indicated by several findings. The blood glucose level has decreased from 468 mg/dL to 310 mg/dL, which, although still above the normal range, is a significant improvement. The pulse rate has normalized from 110/min to 84/min, and the blood pressure has improved from 96/65 mm Hg to 106/76 mm Hg, indicating better cardiovascular stability. The

A. Infuse 0.99% sodium chloride if the solution is not available. B. Obtain the client's weight daily. C. Monitor serum blood glucose during infusion. D. Verify the solution with another RN prior to infusion. E. Increase the rate of infusion if administration is delayed.

Correct Answer is ["B","C","D"]

Explanation

A) Infusing 0.9% sodium chloride is incorrect as it's not appropriate for TPN administration.
B) Obtaining the client's weight daily helps to monitor nutritional status and adjust TPN accordingly.
C) Monitoring serum blood glucose is essential due to the high glucose content in TPN, which can lead to hyperglycemia.
D) Verifying the solution with another RN prior to infusion is a safety measure to ensure the correct solution and dosage.
E) Increasing the rate of infusion if administration is delayed may lead to complications and is not appropriate without medical orders.

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A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg. a fluid intake of 960 mL, and an output of 300 mL in the past 12 hr. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D","E","F","G","H","I","J"]

Explanation

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Correct Answer is ["B","C","D"]

Explanation

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