Question

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

A. Assess the IV line for kinks or obstructions.
B. Administer a bolus of sodium chloride to catch up on the infusion.
C. Document the current intake and continue monitoring.
D. Notify the healthcare provider of the low infusion rate.

Answer 1

The nurse should first assess the IV line for kinks or obstructions. This is important because any obstruction or kink in the IV line can impede the flow of the fluid, resulting in a low infusion rate.

Step-by-step explanation:

The nurse should first assess the IV line for kinks or obstructions (option A). This is important because any obstruction or kink in the IV line can impede the flow of the fluid, resulting in a low infusion rate. The nurse should check the entire length of the IV line, starting from the insertion site to the infusion pump, to ensure that it is free of any blocks or impediments that may be causing the low infusion rate. If the IV line is clear and there are no kinks or obstructions, the nurse can then proceed to further actions if necessary.