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.

Calculate the infused volume.

Complete an incident report.

Assess the client's vital signs.

Answer and Explanation

The Correct Answer is D

The nurse should assess the client's vital signs first to determine if there are any signs of fluid overload, such as hypertension, edema, crackles, or dyspnea. The nurse should then notify the primary care provider.

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Correct Answer is B

Explanation

A nursing incident report is a document that provides detailed information and account of the chain of events leading up to and following an unforeseen circumstance in a healthcare setting or facility especially in the nursing side. An incident report is used to communicate important safety information to hospital administrators and keep them updated on aspects of patient care for risk management, quality assurance, educational, and legal purposes. An incident report should be completed within 24 hours by whomever witnessed the incident or was notified first. In this case, the nurse should complete an incident report because the visitor's fall is an unforeseen circumstance that threatens patient safety and could have legal implications.

A. Deliver a series of high-pitched sounds at random intervals. B. Hold an activated tuning fork against the client's mastoid process. C. Whisper a series of words softly into one ear. D. Place an activated tuning fork in the middle of the client's forehead.

Correct Answer is D

Explanation

Place an activated tuning fork in the middle of the client's forehead. The rationale for this answer is that Weber's test is used to assess for conductive or sensorineural hearing loss by comparing bone conduction in both ears. The nurse places an activated tuning fork in the middle of the client's forehead and asks if the sound is heard equally in both ears or louder in one ear.

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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?

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Naxlex Comprehensive Predictor Exams

A visitor reports to a nurse that she slipped and fell in a client's room. The visitor denies any injury, but is walking with a slight limp. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is conducting the Weber's test on a client. Which of the following is an appropriate action for the nurse to take?

Correct Answer is D

Explanation

A nurse on a medical-surgical unit is caring for a client who reports difficulty sleeping at night. Which of the following findings should indicate to the nurse that the client has sleep deprivation?

A nurse is assessing a client who is receiving continuous IV fluids through a peripheral IV. Which of the following findings indicates to the nurse that the client is experiencing fluid overload?

A nurse is caring for a client who is scheduled to have his alanine aminotransferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse?

A nurse is assessing the visual acuity of a client who wears glasses using a Snellen chart. Which of the following actions should the nurse take?

A nurse is monitoring a client who is receiving continuous IV fluid therapy via a peripheral vein in the left forearm. Which of the following findings indicates that the client has developed phlebitis at the IV site?

A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?

A nurse is assessing an older adult client. Which of the following findings should the nurse expect?