856. A client had a 100 mL bag of 5?xtrose in 0.9% sodium chloride hung at 1500. The nurse making rounds at 1545 finds that the client is complaining of a pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous bag (IV) has 400 mL remaining. The nurse should take which action FIRST? 1. Slow the IV infusion 2. Sit the client up in bed 3. Remove the IV catheter 4. Call the primary health care provider (PHCP) - correct answer Answer: 1 Rationale: the client's symptoms are compatible with circulatory overload. This may be verified by noting that 600mL has been infused in the course of 45 minutes. The first action of the nurse is to slow the infusion. Other actions may be followed in rapid sequence. The nurse may elevate the head of the bed to aid in the client's breathing if necessary. The nurse also notifies the PCHP. the IV catheter is not removed; it may be needed for the administration of medications to resolve the complication. 857. Packed red blood cells have been prescribed for a female client with anemia who has a hemoglobin level of 7.6 g/dL (76 mol/L) and a hematocrit level of 30% (0.30). The nurse takes the client's temperature before the blood transfusion and records 100.6 degrees Fahrenheit (38.1 degrees Celsius) orally. Which action should the nurse take? 1. Begin the transfusion as prescribed 2. Administer an antihistamine and begin the transfusion 3. Administer 2 tablets of acetaminophen 4. Delay hanging the blood and notify the primary health care provider (PHCP) - correct answer Answer: 4 Rationale: If the client has a temperature higher than 100 degrees F, the unit of blood should not be hung until the PHCP is notified and has the opportunity to give further instructions. The PHCP will likely prescribe that the blood be administered regardless of the temperature or may instruct the nurse to administer prescribed acetaminophen and wait until the temperature has decreased before administration, but the decision is not within the nurse's scope of practice to make. The nurse needs a PHCPs prescription to administer medication to the client. 858. The nurse is caring for a client experiencing acute lower gastrointestinal bleeding. In developing the plan of care, which priority problem should the nurse assign to this client?