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Difficulty: MediumPhysiological Adaptation

A practical nurse (PN) is caring for a client with a history of heart failure who is receiving a continuous intravenous (IV) infusion of 0.9% sodium chloride at 150 mL/hr for mild dehydration. During data collection, the PN notes the client's heart rate has increased from 80 to 118 bpm, and blood pressure has risen from 110/70 to 160/90 mmHg. The client becomes newly restless and states, "My chest feels tight and I cannot catch my breath." Which action should the PN take first?

  1. A
    Reassure the client that mild restlessness is a normal reaction to being hospitalized.
  2. Elevate the head of the bed and decrease the IV infusion rate.Answer
  3. C
    Continue the current IV rate and plan to reassess the vital signs in one hour.
  4. D
    Assist the client into a flat, supine position to promote physical rest.

Answer

The correct action is to elevate the head of the bed and decrease the IV infusion rate.
The correct answer directly addresses the client's symptoms of fluid volume overload and impending pulmonary edema. Elevating the head of the bed uses gravity to facilitate lung expansion and improve oxygenation (Breathing priority), while decreasing the IV fluid rate prevents further fluid accumulation in the vascular space (Circulation priority). This is the safest and most immediate prioritization of care before notifying the RN.

Step-by-Step Solution

1
Analyze the clinical cues provided in the scenario.
The client has a rapid heart rate, elevated blood pressure, new-onset restlessness, and shortness of breath while receiving a high-volume IV fluid infusion.
Identifying these cues is necessary to recognize the development of fluid volume overload and impending pulmonary edema, especially in a client with a history of heart failure.
2
Prioritize interventions based on the ABCs (Airway, Breathing, Circulation).
The immediate need is to support the client's breathing and halt the circulatory fluid overload.
Respiratory distress is a life-threatening complication that takes absolute priority over routine monitoring, symptom documentation, or psychosocial reassurance.
3
Determine the appropriate action within the PN scope of practice.
The PN must immediately position the client upright to ease breathing, slow the IV to a keep-vein-open rate to prevent further fluid accumulation, and then escalate the situation to the RN.
These physical interventions quickly and safely stabilize the client's airway and circulation while awaiting further medical orders.

Key Concept

Fluid Volume Overload and ABC Prioritization
Estimated Time:1m 0s
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Topics

Physiological Adaptation

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