What is the first action a nurse should take when a client shows signs of circulatory overload?

What is the first action a nurse should take when a client shows signs of circulatory overload?

• A. Administer prescribed medications
• B. Raise the client's head to aid breathing
• C. Stop the rate of the IV infusion
• D. Notify the health care provider

Answer: (C)

When a client shows signs of circulatory overload, the first action a nurse should take is to stop the rate of the IV infusion. This is the most immediate and crucial step because circulatory overload typically occurs when too much fluid is entering the circulatory system at once, leading to symptoms such as shortness of breath, increased blood pressure, or swelling. By stopping the IV infusion, the nurse directly addresses the cause of the overload and prevents further complications. After halting the infusion, the nurse can then take additional steps to manage the situation effectively, such as raising the client’s head to aid breathing or administering prescribed medications. However, stopping the infusion is the priority because it mitigates the immediate risk to the patient's safety by preventing excessive fluid accumulation. Notifying the healthcare provider is important for further evaluation and management, but it should come after the immediate action of stopping the infusion.

When a client shows signs of circulatory overload, the first action a nurse should take is to stop the rate of the IV infusion. This is the most immediate and crucial step because circulatory overload typically occurs when too much fluid is entering the circulatory system at once, leading to symptoms such as shortness of breath, increased blood pressure, or swelling. By stopping the IV infusion, the nurse directly addresses the cause of the overload and prevents further complications.

After halting the infusion, the nurse can then take additional steps to manage the situation effectively, such as raising the client’s head to aid breathing or administering prescribed medications. However, stopping the infusion is the priority because it mitigates the immediate risk to the patient's safety by preventing excessive fluid accumulation. Notifying the healthcare provider is important for further evaluation and management, but it should come after the immediate action of stopping the infusion.