A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg. a fluid intake of 960 mL, and an output of 300 mL in the past 12 hr. Which of the following actions should the nurse take?

Slow infusion rate and contact the provider.

Lower the head of the bed to semi-Fowler's.

Administer prescribed corticosteroids.

Change infusion to lactated Ringer's and maintain rate.

Answer and Explanation

The Correct Answer is A

A.   The client's dyspnea and elevated blood pressure may indicate fluid volume overload. Slowing the infusion rate and notifying the provider are appropriate actions.
B.   Lowering the head of the bed may help with dyspnea but does not address the underlying cause of fluid overload.
C.   Administering corticosteroids is not indicated based on the client's symptoms and situation.
D.   Changing the infusion to lactated Ringer's may be appropriate, but slowing the infusion rate and assessing the client further are the priority actions.

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Correct Answer is A

Explanation

A) This response offers a solution by involving a social worker who can assist the client in exploring financial assistance programs or alternative medication options.
B) While contacting the pharmacy may be helpful, it does not guarantee a solution to the client's financial constraints.
C) Involving the occupational therapist for a home visit is not directly related to addressing the client's inability to afford medication.
D) Instructing the client to ask their provider to prescribe a cheaper medication puts the responsibility solely on the client and may not address the underlying issue effectively.

A. Limit time for visitors to 2 hr per day. B. Instruct visitors to remain 6 feet from the client. C. Discard the radioactive device in the client's trash can. D. Keep soiled bed linens in the client's room. E. Keep soiled bed linens in the client's room.

Correct Answer is B

Explanation

A) Limiting time for visitors is necessary in this case. However, the time should be limited to 1 hour in 24 hours and not 2 hours.
B) Instructing visitors to remain 6 feet from the client is crucial for their safety to minimize radiation exposure. Brachytherapy involves the use of a radioactive source placed close to or inside the tumor, and while the patient is emitting radiation, safety precautions must be taken to protect others from exposure. Safety measures such as maintaining a safe distance help ensure that the radiation exposure to others is As Low As Reasonably Achievable (ALARA), a principle that aims to minimize exposure while achieving the necessary therapeutic effect.
C) Discarding the radioactive device in the client's trash can is incorrect as it poses a risk of exposure to others.
D) Keeping soiled bed linens in the client's room is incorrect as they may be contaminated with radiation and should be handled according to radiation safety protocols.

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A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg. a fluid intake of 960 mL, and an output of 300 mL in the past 12 hr. Which of the following actions should the nurse take?

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