Canadian Practical Nurse Registration Examination (CPNRE) Practice Exam

In managing a patient with congestive heart failure who presents with a pounding headache, chills, and difficulty breathing, the most appropriate initial action is to decrease the intravenous (IV) rate. This is critical because the symptoms indicate the potential for fluid overload, which is a concern in patients with CHF. Increasing the IV rate could exacerbate the patient’s condition by leading to further fluid retention and worsening heart failure symptoms.

By decreasing the IV rate, you reduce the volume of fluid being infused, which can help alleviate symptoms like difficulty breathing. Additionally, it allows for a more cautious approach to the patient’s fluid management, ensuring that their heart and lungs are not overwhelmed by excess fluids. This step also creates an opportunity to reassess the patient's condition and review the medication plan with consideration of their current symptoms.

While administering pain relief medications might address the headache, it does not tackle the underlying issue related to the fluid overload. Increasing the IV rate could be detrimental, and contacting the physician is important, but it may not be the immediate priority compared to adjusting the IV rate in response to the concerning symptoms present. Therefore, decreasing the IV rate is the most appropriate and immediate action for the nurse to take in this scenario.