Examkin

Question

Difficulty: EasyPhysiological Adaptation

A nurse is caring for a client receiving intravenous (IV) fluids. The client suddenly develops shortness of breath, a cough, and crackles in the lung bases. Arrange the following nursing actions in the priority order they should be performed.

  1. 1Elevate the head of the bed to a high-Fowler's position.
  2. 2Decrease the intravenous fluid infusion rate.
  3. 3Administer supplemental oxygen.
  4. 4Notify the healthcare provider.

Answer

The correct sequence is to elevate the head of the bed, decrease the IV fluid rate, administer oxygen, and then notify the healthcare provider.
In acute decompensation from fluid volume overload, the nurse must follow the airway, breathing, and circulation (ABC) prioritization framework. Elevating the head of the bed immediately improves breathing mechanics. Stopping or slowing the IV fluid prevents further circulatory overload. Administering oxygen supports gas exchange. Finally, notifying the provider is essential to obtain further medical orders once initial stabilization is complete.

Step-by-Step Solution

1
Elevate the head of the bed to a high-Fowler's position.
Improves lung expansion and decreases venous return.
Airway and breathing are the highest priority. Sitting the client up provides the fastest relief for dyspnea.
2
Decrease the intravenous fluid infusion rate.
Stops the infusion of excess volume.
Circulation is the next priority. Slowing the IV fluids prevents the fluid overload from becoming more severe.
3
Administer supplemental oxygen.
Increases oxygen saturation in the blood.
Hypoxia must be treated to ensure adequate tissue perfusion.
4
Notify the healthcare provider.
Facilitates further medical intervention.
Once the client is temporarily stabilized, the provider must be informed to obtain prescriptions for medications like loop diuretics.

Key Concept

Prioritization of care for acute fluid volume overload
Estimated Time:1m 0s
Rate this question

Topics

Physiological Adaptation

More questions from this topic