Question

A nurse initiates a continuous IV infusion on a client. An hour later, the nurse notes the IV solution bag contains the same volume as when therapy was first initiated. Which action does the nurse take?

Bolus the fluid that was not infused

Initiate a new IV access

Flush the IV site with normal saline

Raise the fluid bag higher on the infusion pole

Answer 1

The nurse should raise the fluid bag higher on the infusion pole to increase the pressure differential, thus facilitating the infusion of the IV fluid into the client's bloodstream due to gravitational force.

Step-by-step explanation:

The situation described involves a continuous IV infusion that has not decreased in volume an hour after it was initiated, indicating that the infusion is not successfully delivering fluid to the client. When intravenous infusions are administered, the IV bag must be placed at a sufficient height to help the fluid enter the vein due to gravitational force. To allow the infusion to work properly, it is essential that the IV bag is positioned correctly to overcome venous blood pressure.

Given this information, the appropriate nursing action in this case would typically be to raise the fluid bag higher on the infusion pole, which would increase the gravity-driven pressure differential and facilitate the fluid entering the client's bloodstream. This should be done before attempting other interventions such as reinitiating IV access or administering a bolus, unless the clinical assessment indicates a different issue, such as a kinked line or a clotted IV catheter, which would require specific actions such as flushing the IV line or changing the infusion setup.