A dehydrated patient is rapidly and aggressively treated with a 0.9% sodium chloride IV solution. Which assessment finding would prompt the nurse to discontinue the infusion and call the prescriber?
a. Difficulty breathing
b. Urinary output of 35 mL/hr
c. Diarrhea
d. Rapid heart rate
ANS: A
Aggressive treatment with IV fluids may result in fluid overload, which is manifested by difficulty breathing as a result of fluid in the lungs and heart. The IV infusion should be discontinued, and the prescriber should be notified.
A urinary output of 35 mL/hour is within normal limits.
Diarrhea is not an indication of fluid overload but may occur as a result of changes in osmolality.
A rapid heart rate indicates dehydration, not fluid overload.
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