A nurse hangs a bag of dextrose 5% in water, 1,000 mL at 0800 to run at 125 mL/hr. At 1200, the nurse notices that the client's IV bag is empty. Which of the following interventions should the nurse take first?
Notify the primary care provider.
Assess the client's vital signs.
Calculate the infused volume.
Complete an incident report.
The Correct Answer is B
If a nurse hangs a bag of dextrose 5% in water, 1,000 mL at 0800 to run at 125 mL/hr and notices that the client's IV bag is empty at 1200, the first intervention the nurse should take is to assess the client's vital signs. This will help the nurse determine if the client is experiencing any adverse effects from the rapid infusion of fluids.
Option a is incorrect because notifying the primary care provider is important but not the first intervention.
Option c is incorrect because calculating the infused volume is important but not the first intervention.
Option d is incorrect because completing an incident report is important but not the first intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The nurse should assist the client with a bowel cleansing before an intravenous pyelogram. This helps to ensure that the bowel is empty and that the images obtained during the procedure are clear. The other
a. Oral contrast is not typically used for an intravenous pyelogram.
b. Pain in the suprapubic region is not a common side effect of an intravenous pyelogram.
d. Removing metal objects is important for procedures that use magnetic resonance imaging (MRI), but it is not necessary for an intravenous pyelogram.
Correct Answer is B
Explanation
The correct answer is that the nurse should turn off the faucet with a clean, dry paper towel when performing hand hygiene at the beginning of his shift. This helps to prevent recontamination of the hands by touching the faucet with clean hands.
Options a, c and d are not correct actions for performing hand hygiene. Rubbing hands together to cause friction for at least 10 seconds, drying hands by working from the forearms down to the fingertips and keeping hands above elbow level when washing are not recommended practices for hand hygiene.
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