Question

A client with acute kidney injury (AKI) has a blood pressure of 76/55 mm Hg. The primary health care provider prescribed 1000 mL of normal saline to be infused over 1 hour to maintain perfusion. The client starts to develop shortness of breath. What is the nurse's priority action?

a. Calculate the mean arterial pressure (MAP).
b. Ask for insertion of a pulmonary artery catheter.
c. Take the client's pulse.
d. Decrease the rate of the IV infusion.

Answer 1

The nurse's priority action in this situation is to decrease the rate of the IV infusion.

Step-by-step explanation:

The nurse's priority action in this situation is d. Decrease the rate of the IV infusion. A blood pressure of 76/55 mm Hg indicates hypotension, which means that the client's blood pressure is lower than normal. The shortness of breath could be a sign of fluid overload or fluid shifting into the lungs, which may be exacerbated by the rapid infusion of 1000 mL of normal saline. Decreasing the rate of the IV infusion will help prevent further fluid overload and relieve the client's symptoms.