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 A

Explanation

Rationale:
A. Calcium gluconate is the antidote for magnesium toxicity; it helps reverse the cardiac and neuromuscular effects of hypermagnesemia.
B. IV fluid restriction is not appropriate; often IV fluids are given to promote magnesium excretion.
C. Potassium chloride is not indicated for hypermagnesemia treatment.
D. Increasing magnesium sulfate would worsen hypermagnesemia and is contraindicated.

A. acids B. chemical buffers C. respiratory system D. renal system

Correct Answer is B

Explanation

Rationale:
A. Acids contribute to pH changes but do not defend against them.
B. Chemical buffers are the first line of defense; they react immediately to neutralize excess acids or bases and help maintain pH balance.
C. The respiratory system is the second line of defense, adjusting CO₂ levels to influence pH.
D. The renal system is the third line of defense, regulating acid-base balance by excreting hydrogen ions and reabsorbing bicarbonate, but it acts more slowly.

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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?

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Naxlex Comprehensive Predictor Exams

A client with hypermagnesemia is prescribed calcium gluconate. Which action is appropriate for the nurse to take?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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