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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:
A. The renal system compensates for respiratory acidosis by retaining bicarbonate (HCO₃⁻) and excreting hydrogen ions to help normalize blood pH.
B. The endocrine system regulates hormones, but it is not involved in acid-base compensation.
C. The respiratory system is the cause of the acidosis in this case and therefore cannot compensate.
D. The gastrointestinal system has a minor role in maintaining acid-base balance, but it is not the primary compensatory system for respiratory imbalances.

A. respirations that are labored, and decreased in depth and rate B. respirations that are abnormally deep, regular and increased in rate C. respirations that are regular but abnormally slow D. respirations that cease for several seconds

Correct Answer is B

Explanation

Rationale:
A. Labored and decreased respirations do not describe Kussmaul breathing.
B. Kussmaul respirations are characterized by deep, rapid, and regular breathing as the body attempts to blow off CO₂ to compensate for metabolic acidosis in DKA.
C. Slow respirations are not characteristic of Kussmaul breathing.
D. Respirations that cease are apnea, unrelated to Kussmaul respirations.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Naxlex Comprehensive Predictor Exams

A patient is experiencing respiratory acidosis. Which organ system is responsible for compensation in this patient?

Correct Answer is A

Explanation

A nurse is caring for a client with diabetic ketoacidosis (DKA) and documents that the client is experiencing Kussmaul respirations. Based on this documentation, which of the following did the nurse most likely observe?

Correct Answer is B

Explanation

The nurse is aware that which of the following results when an increased concentration of hydrogen ions occurs within the body fluids?

Use Case Study to answer the following questions. Exhibits Which of the following assessment findings is most concerning in a patient with hypokalemia?

A nurse in a provider's office is collecting data from a client who takes furosemide daily for heart failure. Which of the following findings is a manifestation of hypokalemia?

An emergency department nurse admits a client who has tried to commit suicide by taking an overdose of hydromorphone (Dilaudid), a narcotic. For which acid-base imbalance should the nurse assess this client for?

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?

A nurse is caring for a client who has dyspnea, crackles, and 3+ bilateral pitting pedal edema. Which of the following serum sodium levels should the nurse identify as an indication of fluid volume excess?

The physician has ordered 1 amp of sodium bicarbonate to be added to the client's IVF. The parents of the client want to know what this drug is used for. The student nurse tells the parents that this is commonly given to:

A nurse is planning care for a child who has severe diarrhea. Which of the following actions is the purse's priority?