Question

A client receiving an IV fluid infusion of dextrose 5% and 0.45% normal saline at 125 mL/hr develops restlessness; rapid, shallow respirations; crackles in both lung fields; and distended neck veins. Which action is appropriate for the nurse to implement?

a) Contact the health care provider.
b) Clamp the intravenous catheter.
c) Administer diphenhydramine, as prescribed.
d) Place in the Trendelenburg position.

Answer 1

The appropriate action for the nurse when a client develops signs of fluid overload while receiving an IV fluid infusion is to contact the health care provider.

Step-by-step explanation:

The client showing signs of restlessness, rapid and shallow respirations, crackles in both lung fields, and distended neck veins may be experiencing fluid overload or pulmonary edema related to the intravenous infusion. The appropriate action for the nurse in this situation is a) Contact the health care provider. This is crucial for patient safety and to obtain orders for appropriate interventions, which may include reducing or stopping the IV fluid, administering diuretics, or other medications. Clamping the intravenous catheter without physician's order can be harmful. Diphenhydramine is an antihistamine and is not indicated in this situation. The Trendelenburg position, where the body is laid flat on the back with the feet higher than the head by 15-30 degrees, is not recommended for fluid overload or pulmonary edema and can worsen breathing difficulties.