A nurse is planning care for a client who has hyponatremia and is receiving IV fluid therapy with 3% sodium chloride solution. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

Choice A reason:

Dextrose 5% in water (D5W) is a hypotonic solution that provides free water and calories, but no electrolytes. It is used to treat hypernatremia and cellular dehydration, but it can cause fluid shifts from the intravascular to the intracellular space, leading to cerebral edema and decreased blood pressure. This is not appropriate for a client who has dehydration due to vomiting and diarrhea, as they need to restore their intravascular volume and electrolyte balance.

Choice B reason:

Lactated Ringer's (LR) is an isotonic solution that contains sodium, chloride, potassium, calcium, and lactate. It is used to treat fluid loss from burns, trauma, surgery, or sepsis. It also helps to correct metabolic acidosis by providing bicarbonate precursors. This is the best choice for a client who has dehydration due to vomiting and diarrhea, as they need to replace their fluid and electrolyte losses and maintain their acid-base balance.

Choice C reason:

Dextrose 5% in 0.45% sodium chloride (D5W/0.45% NaCl) is a hypertonic solution that provides free water, calories, and sodium. It is used to treat hypovolemia and hyponatremia, but it can cause fluid shifts from the intracellular to the intravascular space, leading to cellular dehydration and increased blood pressure. This is not appropriate for a client who has dehydration due to vomiting and diarrhea, as they already have low blood pressure and cellular dehydration.

Choice D reason:

Dextrose 5% in lactated Ringer's (D5LR) is a hypertonic solution that provides free water, calories, sodium, chloride, potassium, calcium, and lactate. It is used to treat hypovolemia and metabolic acidosis, but it can cause fluid shifts from the intracellular to the intravascular space, leading to cellular dehydration and increased blood pressure. This is not appropriate for a client who has dehydration due to vomiting and diarrhea, as they already have low blood pressure and cellular dehydration.

Choice A reason:

Applying warm compresses to the site and elevating the arm may help to reduce pain and swelling, but they do not address the underlying cause of the problem, which is likely infiltration or phlebitis of the IV site. Infiltration occurs when the IV fluid leaks into the surrounding tissue, causing edema, coolness, and pallor. Phlebitis occurs when the vein becomes inflamed, causing pain, erythema, and warmth. Both conditions require immediate removal of the IV catheter and restarting a new IV in another site.

Choice B reason:

Slowing down the infusion rate and documenting the findings may be appropriate actions after removing the IV catheter and starting a new IV in another site, but they are not sufficient to resolve the problem. Slowing down the infusion rate may reduce the discomfort and prevent further complications, but it does not stop the leakage or inflammation of the IV site. Documenting the findings is important for legal and quality improvement purposes, but it does not provide any intervention for the patient's pain or risk of infection.

Choice C reason:

Stopping the infusion, removing the IV catheter, and starting a new IV in another site is the most appropriate action by the nurse. This action prevents further damage to the tissue or vein, reduces the risk of infection, and restores adequate IV access for fluid and medication administration. The nurse should also apply a sterile dressing to the affected site, monitor for signs of infection or complications, and notify the physician if needed. This is the correct answer.

Choice D reason:

Notifying the physician and obtaining an order for an antihistamine is not an appropriate action by the nurse. This action implies that the patient is having an allergic reaction to the IV fluid or medication, which is not supported by the assessment findings. An antihistamine may help to reduce itching or swelling, but it does not address the cause of the pain or prevent further tissue or vein damage. The nurse should notify the physician after removing the IV catheter and starting a new IV in another site, and only if there are signs of infection or complications that require medical intervention.