A client receiving a continuous intravenous infusion of 0.9% sodium chloride for dehydration suddenly develops a bounding pulse, jugular venous distention, and a new onset of dyspnea. Auscultation reveals crackles in the bilateral lung bases. Which immediate action should the practical nurse take?
- AInitiate an intravenous push of a loop diuretic as prescribed.
- BInstruct the client to use an incentive spirometer to expand the lungs.
- Halt the intravenous infusion and position the client upright.Answer
- DDocument the lung sounds and plan to reassess the client in 30 minutes.
Answer
The practical nurse should immediately halt the intravenous infusion and position the client upright to address the acute fluid volume overload.
The client is exhibiting classic signs of fluid volume overload, likely due to the continuous intravenous infusion. The priority is to address Airway, Breathing, and Circulation (ABCs). Stopping the infusion prevents further fluid accumulation, and positioning the client upright (e.g., high Fowler's position) decreases venous return and maximizes lung expansion, thereby improving oxygenation. These are critical, immediate actions that fall within the practical nurse's scope of practice before escalating the situation to the registered nurse.
Step-by-Step Solution
Key Concept
Prioritization and Scope of Practice in Fluid Volume Overload