A nurse is preparing to administer intravenous (IV) fluids to a client. The client has a history of heart failure and is currently prescribed diuretics. Which action by the nurse is most appropriate?
A) Administer the IV fluids rapidly to ensure quick hydration.
B) Use a small-bore needle for the IV infusion.
C) Monitor the client for signs of fluid overload.
D) Elevate the client’s legs during the IV infusion.
E) Administer diuretics before initiating the IV fluids.
Rationale: Clients with a history of heart failure are at risk of fluid overload. Monitoring for signs of fluid overload, such as increased blood pressure, edema, and respiratory distress, is crucial to prevent complications. Administering IV fluids rapidly or using a small-bore needle may exacerbate fluid overload. Elevating the client’s legs may not address the underlying issue. Administering diuretics before IV fluids could further contribute to dehydration.
A nurse is caring for a postoperative client who is receiving intravenous (IV) fluids. The client reports sudden shortness of breath and chest pain. What is the nurse’s priority action?
A) Assess the client’s pain level.
B) Administer an analgesic medication.
C) Document the findings in the chart.
D) Stop the IV infusion immediately.
E) Increase the IV fluid infusion rate.
Rationale: Sudden shortness of breath and chest pain may indicate a possible fluid overload or pulmonary embolism. The nurse’s priority is to stop the IV infusion immediately to prevent further complications and assess the client’s respiratory status. Assessing pain, administering analgesics, and documenting findings are important but secondary to addressing the acute respiratory distress. Increasing the IV fluid infusion rate could worsen the situation.
A client with severe dehydration is prescribed intravenous (IV) fluids. The client has a known allergy to a specific antibiotic. What is the nurse’s appropriate action?
A) Administer the IV fluids and monitor for any allergic reactions.
B) Consult with the healthcare provider to change the antibiotic.
C) Administer the antibiotic slowly to minimize the risk of an allergic reaction.
D) Administer the antibiotic as prescribed, as dehydration takes precedence.
E) Withhold both the IV fluids and the antibiotic to avoid complications.
Rationale: The client’s known allergy to a specific antibiotic requires the nurse to consult with the healthcare provider to change the antibiotic. Administering the antibiotic as prescribed may lead to a severe allergic reaction. Administering IV fluids without addressing the antibiotic allergy may compromise the client’s safety. Administering the antibiotic slowly does not eliminate the risk of an allergic reaction. Withholding both the IV fluids and the antibiotic is not ideal, as dehydration still needs to be addressed with an alternative antibiotic.
A nurse is preparing to administer intravenous (IV) fluids to a client with dehydration. The healthcare provider orders lactated Ringer’s solution. What is the nurse’s priority action before administering lactated Ringer’s?
A) Verify the client’s blood type.
B) Assess the client’s potassium levels.
C) Confirm the absence of lactose intolerance.
D) Check the client’s temperature.
E) Obtain an order for a different IV fluid.
Rationale: Lactated Ringer’s solution contains lactate, and some clients may be intolerant to lactose. Confirming the absence of lactose intolerance is crucial to prevent adverse reactions. Verifying blood type, assessing potassium levels, and checking temperature are important but unrelated to lactated Ringer’s administration. Obtaining an order for a different IV fluid should only be considered if lactose intolerance is confirmed.
A postoperative client is prescribed normal saline for IV fluid replacement. The client has a history of heart failure. What assessment finding should the nurse prioritize when administering normal saline?
A) Skin turgor and moisture.
B) Blood pressure and heart rate.
C) Urine output and color.
D) Respiratory rate and pattern.
E) Serum electrolyte levels.
Rationale: Clients with a history of heart failure may be sensitive to fluid volume changes. Monitoring blood pressure and heart rate is crucial to detect any signs of fluid overload, a potential complication of normal saline administration. Skin turgor, urine output, respiratory rate, and electrolyte levels are important assessments but are secondary to addressing cardiovascular stability.
A client admitted with severe diarrhea is prescribed intravenous (IV) fluids. The healthcare provider orders a combination of lactated Ringer’s and normal saline. What is the nurse’s appropriate action?
A) Administer the IV fluids separately but through the same IV line.
B) Mix lactated Ringer’s and normal saline in a single IV bag.
C) Administer lactated Ringer’s first, followed by normal saline.
D) Administer normal saline first, followed by lactated Ringer’s.
E) Request clarification from the healthcare provider on the order.
Rationale: Combining lactated Ringer’s and normal saline in the same IV bag may lead to precipitation and is not recommended. Administering them separately through the same IV line or in a specific sequence requires clarification from the healthcare provider to ensure safe administration. Requesting clarification ensures that the nurse follows the correct protocol and prevents potential complications associated with incompatible IV fluids.
A client is admitted with severe dehydration, and the healthcare provider orders lactated Ringer’s solution. The nurse notes that the client has a history of renal impairment. What is the nurse’s priority action?
A) Administer lactated Ringer’s as ordered.
B) Consult with the healthcare provider to change the IV fluid.
C) Increase the infusion rate to promote faster rehydration.
D) Assess the client’s blood glucose levels.
E) Administer a loop diuretic before the IV fluids.
Rationale: Lactated Ringer’s solution contains potassium, and clients with renal impairment may be unable to excrete excess potassium effectively. Changing the IV fluid to one with a lower potassium content is essential to prevent hyperkalemia. Administering lactated Ringer’s as ordered may pose a risk of elevated potassium levels. Increasing the infusion rate without addressing the potassium concern is not safe. Assessing blood glucose levels and administering a loop diuretic are unrelated to the primary issue of potassium content in lactated Ringer’s.
A postoperative client is prescribed normal saline for IV fluid replacement. The client has a known allergy to sodium chloride. What is the nurse’s immediate action?
A) Administer the normal saline slowly.
B) Notify the healthcare provider of the allergy.
C) Administer the normal saline as ordered.
D) Request an alternative IV fluid.
E) Pre-medicate the client with an antihistamine.
Rationale: A known allergy to sodium chloride necessitates the nurse to request an alternative IV fluid to avoid an allergic reaction. Administering normal saline, even slowly, may still trigger an allergic response. Notifying the healthcare provider is important, but the immediate action should be to ensure the client receives a safe IV fluid. Administering the normal saline as ordered and pre-medicating with an antihistamine do not address the allergy concern.
A client admitted with severe diarrhea is prescribed intravenous (IV) fluids. The healthcare provider orders lactated Ringer’s and normal saline concurrently. What is the nurse’s appropriate action?
A) Administer both IV fluids simultaneously through separate IV lines.
B) Mix lactated Ringer’s and normal saline in a single IV bag.
C) Administer lactated Ringer’s first, followed by normal saline.
D) Administer normal saline first, followed by lactated Ringer’s.
E) Request clarification from the healthcare provider on the order.
Rationale: Administering different IV fluids concurrently may lead to incompatibilities or precipitation. Requesting clarification from the healthcare provider ensures safe administration and prevents potential complications. Administering both fluids simultaneously or in a specific sequence without clarification poses a risk to the client. Mixing lactated Ringer’s and normal saline in a single IV bag may result in chemical interactions that compromise the integrity of the fluids.
A client is receiving lactated Ringer’s solution via IV infusion. The nurse notes swelling and redness at the infusion site. What is the nurse’s immediate action?
A) Stop the IV infusion immediately.
B) Document the findings and continue the infusion.
C) Assess the client’s blood pressure.
D) Apply a warm compress to the infusion site.
E) Increase the IV fluid infusion rate.
Rationale: Swelling and redness at the infusion site may indicate infiltration or an allergic reaction. The nurse’s immediate action is to stop the IV infusion to prevent further complications. Documenting the findings is important but secondary to ensuring client safety. Assessing blood pressure is not the priority when faced with a potential infusion reaction. Applying a warm compress may be appropriate for infiltration but not for an allergic reaction. Increasing the IV fluid infusion rate is contraindicated in the presence of an adverse reaction.
