During a change-of-shift report, a nurse sees that a client's IV bag of 0.9% sodium chloride has 900 mL of fluid left in it. The nurse makes rounds 30 min later and notes that the IV bag is empty. Which of the following actions should the nurse take?

Elevate the head of the bed to high Fowler's.

Check the client's respiratory rate and lung sounds

Measure the client's temperature.

Request NPO status for the client.

Answer and Explanation

The Correct Answer is B

Rationale:
A. Elevating the head of the bed is appropriate for respiratory distress, but the priority is to assess for signs of fluid overload.
B. The IV infused 900 mL in just 30 minutes, which is a dangerously rapid rate and can lead to fluid volume overload, especially in vulnerable clients. The nurse should assess for signs such as increased respiratory rate and crackles in the lungs, indicating pulmonary edema.
C. Measuring temperature is not the priority in this situation and does not relate directly to fluid overload.
D. NPO status does not address the immediate concern of a rapid IV infusion and its potential consequences.

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Correct Answer is C

Explanation

Rationale:
A. While nosebleeds should be reported, this is not an administration instruction.
B. Cleaning the nostril before and after is not typically required and could irritate mucosa.
C. Alternating nostrils daily helps prevent irritation and promotes better absorption, which is the correct teaching.
D. Vitamin D supplements may increase calcium levels, which is contraindicated in hypercalcemia.

A. Counting the number of wet diapers every shift B. Measuring the infant's head circumference twice per day C. Weighing the infant at the same time every day, with the same amount of clothing on. D. Taking the infant's vital signs every 2 hr

Correct Answer is C

Explanation

Rationale:
A. Counting wet diapers provides general insight into fluid output, but it is not the most accurate measure of overall fluid status.
B. Measuring head circumference is useful for assessing neurological changes or growth, not hydration.
C. Daily weight is the most accurate and sensitive indicator of fluid balance in infants, especially when performed consistently.
D. Vital signs can reflect dehydration, but they are less reliable than daily weight for ongoing monitoring of rehydration progress.

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During a change-of-shift report, a nurse sees that a client's IV bag of 0.9% sodium chloride has 900 mL of fluid left in it. The nurse makes rounds 30 min later and notes that the IV bag is empty. Which of the following actions should the nurse take?

Nursing Test Bank

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Explanation

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