The nurse is caring for a patient who is receiving isotonic intravenous (IV) fluids at an infusion rate of 125 mL/hour
The nurse performs an assessment and notes a heart rate of 102 beats per minute, a blood pressure of 160/85 mm Hg, and crackles auscultated in both lungs. Which action will the nurse take?
a. Decrease the IV fluid rate and notify the provider.
b. Increase the IV fluid rate and notify the provider.
c. Request an order for a colloidal IV solution.
d. Request an order for a hypertonic IV solution.
ANS: A
The patient shows signs of fluid volume excess, so the nurse should slow the IV fluid rate and notify the provider. Increasing the rate would compound the problem. Colloidal and hypertonic fluids would pull more fluids into the intravascular space and compound the problem.
You might also like to view...
If a client has a total blood cholesterol of 246 mg/dL and a low-density lipoprotein cholesterol level of 172 mg/dL, their blood cholesterol level would be considered to be
a. low. b. desirable. c. borderline high. d. high.
A nurse is looking to create health policies in the community to promote healthy aging. Which of the following would likely be successful?
A. Programs that promote nutritious eating choices and maintaining a healthy weight in young children B. Increasing access to alternative medications and treatments for common diseases in the elderly C. Free or reduced public transportation costs for people over the age of 65 D. Increased access to education
In rare situations, it may be necessary for the provider to give verbal orders. These orders are legal and must be signed by the provider as soon as possible. Based on this information, who is the best individual to take verbal orders?
A) Nursing student B) Nursing assistant C) Unit secretary D) Licensed nurse
It has been determined that all of the following clients are at risk for falling. Which one requires the nurse's priority for ambulation?
1. A 16-year-old with a sprained ankle being discharged from the emergency de-partment 2. A 54-year-old who has taken the initial dose of an antihypertensive medication 3. A 45-year-old postoperative client up for the first time since knee surgery 4. An 81-year-old who is asthmatic and had a hip replaced 18 months ago