The client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 15:00. The nurse, making rounds at 15:45, finds the client is complaining of a pounding headache, is dyspneic with chills, is apprehensive, and has an increased pulse rate
The intravenous (IV) bag has 400 mL remaining. The nurse should take which of the following actions first? 1. Shut off the infusion.
2. Sit the client up in bed.
3. Remove the angiocatheter and IV.
4. Place the client in Trendelenburg's position.
1
Rationale: The client's symptoms are compatible with speed shock (fluid volume overload). This may be verified by noting that 600 mL has infused in the course of 45 minutes. The first action of the nurse from the options presented is to shut off the infusion. The nurse may elevate the head of bed to aid the client's breathing. Placing the client in Trendelenburg's position is not an appropriate action and will increase the dyspnea. The nurse also notifies the physician. The angiocatheter does not need to be removed. It may continue to be needed when the complication has been managed.
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