The prescription for the client's IV infusion reads, "100 ml/hr.". The nurse observes the client's IV infused 125 ml in addition to the intended volume after 2 hours. Which is the most important intervention for the nurse to implement?

Question

1. Compare weight to baseline data.
2. Replace the infusion pump batteries.
3. Assess client for respiratory distress.
4. Reduce infusion rate below 75 ml/hr.

Answer 1

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3. The nurse assesses the client for respiratory distress after an excessive infusion of 125 ml of IV fluid because excess total body fluid often leaks into the pulmonary vascular bed to decrease gas exchange. This potentially leads to hypoxemia and dyspnea because the client has difficulty with oxygenation and there can be enough fluid overload to precipitate heart failure in a client with heart disease or respiratory failure in a client with pulmonary disease.
1. Weighing the client is a reasonable nursing intervention to differentiate client weight gain from fluid or caloric intake. Verifying client safety and well-being is a better choice and is more important than differentiating the weight because the extra fluid can cause dyspnea, desaturation, and heart failure.
2. Checking the infusion pump batteries is a reasonable intervention if the pump op-erates on battery power; however, most infusion pumps operate on 110 v. The re-chargeable battery is intended to bridge short-term gaps in 110-v power. Most infu-sion pumps do not operate with small, single-use batteries that need replacing.
4. The nurse can reduce the infusion rate to 75 ml/hr after collaborating with the pro-vider. The nurse cannot change the infusion rate because doing so is equivalent to practicing medicine.