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 minutes later and notes that the IV bag is empty.
Which of the following actions should the nurse take?

Check the client's respiratory rate and lung sounds.

Request NPO status for the client.

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

Measure the client's temperature.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Check the client's respiratory rate and lung sounds When an IV bag is unexpectedly empty, it is important to assess the client for potential complications, especially if the client was receiving fluid therapy. Checking the respiratory rate and lung sounds is essential to ensure there are no signs of respiratory distress, such as crackles or wheezing, which could indicate fluid overload or a pulmonary issue.

Choice B rationale:

Request NPO status for the client Requesting nothing by mouth (NPO) status is not the immediate action required when an IV bag is empty. The priority is to assess the client's condition and address any potential issues first.

Choice C rationale:

Elevate the head of the bed to high Fowler's Elevating the head of the bed to high Fowler's is a measure to assist with preventing aspiration during oral intake. It is not the primary action required in this situation, where assessing the client's respiratory and fluid status is more important.

Choice D rationale:

Measure the client's temperature Measuring the client's temperature is not the immediate priority in this scenario. Assessing the client's respiratory and fluid status is more critical to identify any potential issues associated with the empty IV bag. .

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Correct Answer is C

Explanation

Choice A rationale:

Providing samples for sputum cultures every 6 weeks is not a necessary instruction for a client with pulmonary tuberculosis. Sputum cultures are typically performed at specific intervals to monitor the progress of treatment and assess for bacterial resistance. This information is essential for healthcare providers but not for the client's daily care and safety.

Choice B rationale:

Consuming alcohol in moderation while taking antituberculosis medications is not recommended. Alcohol can interact with these medications and reduce their effectiveness. It is essential to advise the client to avoid alcohol completely while on tuberculosis treatment to ensure the best possible outcome.

Choice C rationale:

Wearing a mask while out or around crowds of people is a crucial precaution to prevent the spread of tuberculosis, which is highly contagious. Tuberculosis is transmitted through the air when an infected person coughs or sneezes, making mask-wearing an effective measure to protect both the client and others. This instruction promotes the safety of the client and the community.

Choice D rationale:

Placing tissue soiled with respiratory secretions in a paper bag for later disposal is not a recommended practice. Infectious material should be properly disposed of in biohazard containers or bags designed for infectious waste. This instruction does not follow the standard safety protocols for managing infectious materials and is not in the best interest of the client's health.

A. Chloride 99 mEq/L. B. Sodium 126 mEq/L. C. Magnesium 1.9 mg/dL. D. Potassium 3.6 mEq/L.

Correct Answer is B

Explanation

Choice A rationale:
Chloride 99 mEq/L. Rationale: A chloride level of 99 mEq/L is within the normal range, which is typically around 96-106 mEq/L. There is no need to report this value to the provider as it is not indicative of a significant abnormality.
Choice C rationale:
Magnesium 1.9 mg/dL. Rationale: A magnesium level of 1.9 mg/dL is within the normal range, which is generally about 1.5-2.5 mg/dL. This value is not indicative of a significant abnormality and does not require immediate reporting to the provider.
Choice D rationale:
Potassium 3.6 mEq/L. Rationale: A potassium level of 3.6 mEq/L is within the normal range, which is typically around 3.5-5.0 mEq/L. While it's on the lower side of the normal range, it is not low enough to warrant immediate reporting to the provider. However, the nurse should continue to monitor the client's potassium levels and address any potential issues if they persist or worsen.
Choice B rationale:
Sodium 126 mEq/L. Rationale: A sodium level of 126 mEq/L is below the normal range, which is typically around 135-145 mEq/L. Hyponatremia, or low sodium levels, can be a serious condition that can lead to neurological symptoms and other complications. Therefore, the nurse should promptly report this finding to the provider so that appropriate interventions can be initiated.

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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 minutes later and notes that the IV bag is empty.Which of the following actions should the nurse take?

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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 minutes later and notes that the IV bag is empty.
Which of the following actions should the nurse take?