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 B

Explanation

Before administering enteral feedings via an NG tube, the nurse should check for gastric residual volume to ensure that the client is able to tolerate the feeding. If the residual volume is high, it may indicate delayed gastric emptying and the feeding may need to be delayed or the rate adjusted.

a. Encouraging the client to take sips of water may help maintain hydration, but it is not necessary prior to administering enteral feedings.

c. Flushing the tube with sterile 0.9% sodium chloride irrigation can help maintain patency of the tube, but it is not necessary prior to administering enteral feedings.

d. Encouraging the client to breathe deeply and cough can help clear secretions from the lungs, but it is not necessary prior to administering enteral feedings.

A. Decreased judgment B. Decreased activity C. Increased reﬂexes D. Increased auditory alertness

Correct Answer is A

Explanation

Decreased judgment is a common sign of sleep deprivation. When a person is sleep deprived, their cognitive function can be impaired, leading to difficulty making decisions and exercising good judgment.

Options b, c, and d are not necessarily indicative of sleep deprivation. Decreased activity can be a sign of many diﬀerent conditions, including fatigue or depression. Increased reﬂexes and increased auditory alertness are not commonly associated with sleep deprivation.

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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

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