The prescription for the patient's intravenous (IV) infusion reads, "100 mL/hr.". The nurse observes that the patient's IV line infused 125 mL in addition to the ordered volume after 2 hours
Which is the most important intervention for the nurse to implement? a. Compare weight to baseline data.
b. Replace the infusion pump batteries.
c. Assess the patient for respiratory distress.
d. Reduce the infusion rate below 75 mL/hr.
C
The nurse assesses the patient 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 may lead to hypoxemia and dyspnea because the patient has difficulty with oxy-genation, and there can be enough fluid overload to precipitate heart failure in a patient with heart disease or respiratory failure in a patient with pulmonary disease. Weighing the patient is a reasonable nursing intervention to differentiate patient weight gain from fluid or caloric intake. Verifying patient safety and well-being is a better choice and is more important than differen-tiating the weight because the extra fluid can cause dyspnea, desaturation, and heart failure. Checking the infusion pump batteries is a reasonable intervention if the pump operates on battery power. The nurse can reduce the infusion rate to 75 mL/hr after collaborating with the health-care provider. The nurse cannot change the infusion rate because doing so is equivalent to prac-ticing medicine.
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