What should the nurse do first? A client with heart failure has been - ProProfs Discuss
Topics
Products
Follow Us:

What should the nurse do first? A client with heart failure has been receiving an I.V. infusion at 125 ml/hour. Now the client is short of breath and the nurse notes bilateral crackles, jugular vein distention, and tachycardia.



A. Notify the physician.
B. Discontinue the I.V. catheter.
C. Administer a ordered diuretic.
D. Slow the I.V. infusion.

This question is part of

The Nursing Process
Asked by Morgan, Last updated: Apr 04, 2020

+ Answer
Request

2 Answers

C. Marcus

C. Marcus, Content Developer, Washington

Answered Oct 23, 2018

Tachycardia is a situation when the heart rate is more than 100 beats per minute. It can be part of the body's response to anxiety, fever, rapid blood loss, strenuous exercise, and elevated amounts of your thyroid hormones.

Tachycardia caused by heart or lung disease often is accompanied often accompanied by chest pain, shortness of breath, or lightheadedness. The influx of IV fluids for heart failure patients may worsen their condition. This is because excess fluids in the bloodstream may cause further strain on the body. Diuretics are also commonly used.

 

John Smith

John Smith

Answered Sep 09, 2016

Slow the i.v. infusion.-rationale: because this client has fluid overload, the nurse should first slow the infusion to prevent additional fluid overload, then notify the physician and obtain further orders. notifying the physician without slowing the infusion would put the client at risk for pulmonary complications or respiratory failure. discontinuing the catheter is inappropriate because the nurse may still need vascular access to administer i.v. fluids (at a decreased rate) or additional i.v. medications. administering a diuretic without changing the i.v. infusion rate wouldnt prevent fluid overload from recurring. client needs category: physiological integrity client needs subcategory: reduction of risk potential cognitive level: analysis reference: craven, r.f., and hirnle, c.j. fundamentals of nursing: human health and function, 5th ed. philadelphia: lippincott williams & wilkins, 2007, p. 626.
 

Search for Google images
Select a recommended image
Upload from your computer
Search for Google images
Select a recommended image
Upload from your computer
Search for Google images
Select a recommended image
Upload from your computer

Email Sent
We have sent an email to your address "" with instructions to reset your password.