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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

The nurse should ask a second nurse to record her signature when wasting any unused portion of the controlled substance. This is a standard procedure for the safe handling and documentation of controlled substances.

a. The nurse should report any discrepancy in the count total of the controlled substance before administration, not after.

b. The wasted portion of the controlled substance should be disposed of according to facility policy, which may not involve placing it in a sharps container.

c. The count total of the controlled substance should be verified before removing the amount needed, not after.

A. Ask the client to shower 3 times the day before surgery. B. Explain the need to have another adult drive the client home following surgery. C. Instruct the client to stop drinking clear liquids 1 hour before surgery. D. Inform the client that they can wear makeup during surgery.

Correct Answer is B

Explanation

When providing preoperative teaching to a client over the phone in preparation for outpatient surgery, the nurse should explain the need for the client to have another adult drive them home following surgery. This is because the client may still be aﬀected by anesthesia and may not be able to safely operate a vehicle.

a. Asking the client to shower 3 times the day before surgery is not necessary and may dry out the skin.

c. The client should typically stop drinking clear liquids 2 hours before surgery, not 1 hour.

d. The client should not wear makeup during surgery as it can interfere with the monitoring of their skin color and oxygen saturation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a controlled substance to a client for pain management. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is providing preoperative teaching to a client over the phone in preparation for outpatient surgery. Which of the following information should the nurse include in the teaching?

Correct Answer is B

Explanation

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