An older male patient receiving normal saline 0.9% through IV line complaining shortness of breath and palpitation. The patient's assessment finding reveals that central venous pressure (CVP) is 18 cm H2O. What would be the priority nursing intervention?

Appeared in: NORCET -4 , 2023

Explanation

The patient's symptoms (shortness of breath, palpitations) and high CVP (18 cm H2O) are definitive signs of fluid volume overload.
The immediate priority in any life-threatening IV complication is to stop the causative agent.
Discontinuing the IV fluid is the fastest and most direct intervention to prevent the patient's condition from worsening.
This action falls within the nurse's independent scope of practice to ensure immediate patient safety.

Option A: Continuing the infusion would directly worsen the fluid overload, increase respiratory distress, and could lead to acute pulmonary edema.
Option B: Increasing the flow rate is extremely dangerous and would rapidly accelerate the patient's decline, potentially causing cardiac arrest.
Option D: While notifying the physician is a critical step, it is not the first priority. The nurse must act immediately to stop the harm before making the call. Delaying the intervention to call first could be fatal.

Clinical Relevance

Nursing practice connection: Safe nursing care depends on performing Priority nursing interventions for circulatory overload (fluid volume excess) secondary to IV therapy in the correct sequence, documenting the action clearly, and monitoring for the expected response.
Nurses must be vigilant in monitoring patients receiving IV fluids, especially vulnerable populations like the elderly, for signs of fluid overload.
Recognizing the early signs (e.g., cough, dyspnea, crackles, elevated CVP) and intervening immediately by stopping the infusion is a critical patient safety responsibility.
What if the patient's CVP was normal (e.g., 6 cm H2O)? The nurse would still slow the IV as a precaution but would prioritize investigating other causes for the symptoms, such as an allergic reaction, anxiety, or a pulmonary embolism, as fluid overload would be less likely.

How to Approach the Question

First, analyze the patient data provided in the stem. Identify subjective complaints (shortness of breath, palpitations) and objective data (older male, receiving IV fluids, CVP of 18 cm H2O).
Synthesize the data to identify the core clinical problem. The combination of symptoms and a very high CVP points directly to fluid volume overload.
Next, evaluate the question, which asks for the 'priority' nursing intervention. This means you must select the action that is most critical and should be done first.
Apply the nursing principle of patient safety: in an acute, life-threatening situation caused by a treatment, the first step is always to stop the treatment.
Evaluate the options based on this principle. Discontinuing the fluid is the only option that directly stops the cause of the harm. Notifying the physician is a secondary, though essential, action.

Concept Tested & Keywords

Concept Tested: Priority nursing interventions for circulatory overload (fluid volume excess) secondary to IV therapy.
Stem keywords: older male patient, normal saline 0.9%, IV line, shortness of breath, palpitation, central venous pressure (CVP), 18 cm H2O, priority nursing intervention
Lead-in keywords: priority
Clinical cues: CVP is 18 cm H2O (Normal: 3-8 cm H2O), indicating significant fluid volume excess.
Clinical cues: Shortness of breath and palpitations during IV infusion are classic signs of circulatory overload.

QKVtKAjUfvZr7_w9eEyDq4

E6 Nursing Fundamentals Taylor p. 834-836

E6 Nursing Fundamentals Potter Perry 12e Part 5 p. 106-108

E6 Pharmacology Nursing Lilley 11e Part 2 p. 172-174

Practise the full NORCET -4 , 2023

Attempt every question from this paper in a timed mock, then review the full solution for each one.