Difficulty: Medium
Average Score: 89%
Full-length
Passage / Scenario
An elderly client receiving IV fluids of 0.9% NaCl at 125 cc/h into her left arm. During a routine assessment, the nurse finds that the client has distended neck veins, shortness of breath, and crackles in both lung bases.The nurse should
Correct answer
A
Rationale
Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? No. Determine the outcome of each implementation. (1) correct-KVO (20 cc/h) will keep access open (2) need to notify physician, rate still too much since patient is in fluid overload (3) IV line may be necessary, diuretics may be ordered (4) description indicates circulatory overload, not infiltration