A nurse is discussing adverse reactions to pain medications in older adult clients with a newly licensed nurse.

Which of the following findings should the nurse include as risk factors for an adverse drug reaction? (Select all that apply)

This will help reduce swelling and discomfort caused by the infiltration of fluid into the tissues. Elevating the extremity also promotes venous return and prevents further fluid accumulation.

Choice A is wrong because applying pressure to the IV site can increase the risk of tissue damage and infection.

Pressure can also obstruct blood flow and cause thrombophlebitis.

Choice C is wrong because slowing the infusion rate will not stop the infiltration of fluid into the tissues.

Slowing the infusion rate can also delay the delivery of medication or fluid to the client.

Choice D is wrong because flushing the IV catheter can worsen the infiltration of fluid into the tissues.

Flushing the IV catheter can also introduce air or bacteria into the bloodstream and cause complications.

Normal ranges for peripheral IV infusion are dependent on the type and volume of fluid, the size and location of the catheter, and the condition of the client. Generally, peripheral IV infusion rates should not exceed 100 mL/hr for adults and 60 mL/hr for children.

This is because a weight gain of 2.5 kg (5 Ib) in 2 days indicates a worsening of heart failure and fluid retention, which may require an adjustment of the diuretic dose or other medications.

The provider should be informed of this change as soon as possible to prevent further complications.

Choice A is wrong because teaching the client about foods low in sodium is not the first action the nurse should take.

While a low-sodium diet is important for heart failure patients, it is not an urgent intervention and it does not address the immediate problem of fluid overload.

Choice B is wrong because determining medication adherence by the client is not the first action the nurse should take.

While it is important to assess if the client is taking furosemide as prescribed, it is not an urgent intervention and it does not rule out other causes of fluid retention, such as renal impairment or disease progression.

Choice C is wrong because encouraging the client to dangle the legs while sitting in a chair is not the first action the nurse should take.

While this may help reduce edema in the lower extremities, it does not address the underlying cause of fluid overload and it may worsen pulmonary congestion by increasing venous return to the heart.