Question

A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hr. Which of the following actions should the nurse take?

A) Increase the IV rate to catch up on the fluid.
B) Document the findings and continue to monitor the IV infusion.
C) Assess the patency of the IV line and the infusion rate accuracy.
D) Notify the healthcare provider for further orders.

Answer 1

The correct action the nurse should take is to assess the patency of the IV line and verify the accuracy of the infusion rate. If issues are found, they need to be rectified before considering changing the fluid rate.

Step-by-step explanation:

The student is asking about the appropriate nursing action when a client's intravenous (IV) infusion of 0.9% sodium chloride is not infusing at the prescribed rate. The prescribed rate is 125 mL/hr, but the client has only received 80 mL over the last 2 hours. The nurse should not simply increase the IV rate without first assessing the situation. Therefore, the correct action would be:

C) Assess the patency of the IV line and the infusion rate accuracy. After ensuring the IV line is patent and that the infusion pump (if used) is set correctly, the nurse should then determine the cause of the slow infusion and correct it. This may mean adjusting the IV pump settings or repositioning the IV line. Only after the cause has been rectified should the nurse consider adjusting the fluid rate, and this should be done per the healthcare provider’s instructions.

Once the situation is corrected, the nurse can then document the findings and continue to monitor, as well as notify the healthcare provider if necessary.