51. A client returns from an operating room. The client's IV is running at 150 mL/hr; pulse is 90 and full; respirations are moist and wheezy. A nurse's initial action should be to:
51. A client returns from an operating room. The client's IV is running at 150 mL/hr; pulse is 90 and full; respirations are moist and wheezy. A nurse's initial action should be to:
. Speed up the IV and call the physician.
. Check the electrolyte levels.
. Report the IV rate to the charge nurse.
. Slow down the IV and call the physician.
Test-Taking Tip
Think about what happens when the heart cannot handle the circulating volume overload, requiring ↓ IV rate and calling the physician.
Content Area: Adult Health, Fluid and Electrolyte Imbalances; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Medical Emergencies
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Answer 1 is incorrect because the pulse rate and moist respirations may be due to the rapid IV rate. Answer 2 is incorrect because the nurse needs to do something immediately. Answer 3 is incorrect because only the physician can provide orders to correct the possible volume overload. Answer 4 is correct because the assessment may indicate volume overload. Slowing the IV rate keeps the IV access open while waiting for further orders.