Question

A client is admitted for dehydration, and an intravenous (IV) infusion of normal saline at 125 mL/hr has been started. One hour after the IV initiation the client begins screaming, "I can't breathe!" The nursing priority action is:

1. Discontinue the IV site and contact the primary health care provider

2. Elevate the head of the bed and obtain vital signs

3. Contact the primary health care provider to obtain a prescription for a sedative

4. Assess for allergies and change the IV to an intermittent infusion device

Answer 1

The nursing priority when a client cannot breathe following IV initiation is to elevate the head of the bed and obtain vital signs, helping to ease breathing and assess the patient's condition before taking further action.

Step-by-step explanation:

The nursing priority action for a client screaming "I can't breathe!" one hour after the initiation of an intravenous (IV) infusion is to elevate the head of the bed and obtain vital signs. This helps to ensure the patient can breathe more easily and also provides essential information regarding their current physiological state. It is crucial to assess the patient's airway, breathing, and circulation immediately. Elevating the head of the bed can assist in easing breathing difficulties, and obtaining vital signs is an integral part of assessing the severity of the patient's condition and for making further clinical decisions.

Directly contacting the healthcare provider becomes pertinent if the vital signs indicate distress or if there is no improvement following initial interventions. Discontinuing the IV without evidence that it is causing the problem could be premature, and administering a sedative without a clear diagnosis could be dangerous. It is essential to assess for possible fluid overload or anaphylaxis, which could be indicated by difficulty breathing post-IV initiation, though allergies are less likely with normal saline.