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","D","E"]

Explanation

Choice A rationale:

Gastrointestinal bloating is not a typical clinical manifestation of left-sided heart failure. Left-sided heart failure primarily affects the pulmonary circulation, leading to symptoms such as dyspnea and orthopnea, but not gastrointestinal symptoms.

Choice B rationale:

Jugular vein distention is more commonly associated with right-sided heart failure. In left-sided heart failure, the congestion typically occurs in the pulmonary circulation, leading to respiratory symptoms, whereas jugular vein distention is a sign of elevated central venous pressure often seen in right-sided heart failure.

Choice C rationale:

Tachycardia is a common clinical manifestation of left-sided heart failure. As the heart struggles to pump blood effectively, it compensates by increasing the heart rate to maintain cardiac output.

Choice D rationale:

Orthopnea is a classic symptom of left-sided heart failure. Clients with left-sided heart failure often experience difficulty breathing when lying flat and find relief when sitting upright. This is due to the redistribution of blood in the lungs when changing positions.

Choice E rationale:

Dyspnea is another hallmark symptom of left-sided heart failure. It is caused by the accumulation of fluid in the lungs (pulmonary edema) due to the impaired ability of the left ventricle to effectively pump blood, leading to congestion in the pulmonary circulation.

A. Have the client cough and expectorate secretions. B. Instruct the client to use a pursed-lip breathing technique. C. Increase the oxygen flow to 3 L/min. D. Evaluate the client's respiratory status.

Correct Answer is D

Explanation

Choice A rationale:

Having the client cough and expectorate secretions is a reasonable intervention for managing respiratory distress, but it is not the top priority. The nurse should first assess the client's overall respiratory status to determine the severity of the problem.

Choice B rationale:

Instructing the client to use a pursed-lip breathing technique is a helpful strategy to improve breathing in some cases. However, it should not be the top priority when a client is experiencing difficulty breathing. Assessment should come first.

Choice C rationale:

Increasing the oxygen flow to 3 L/min without a proper assessment is not advisable. It's essential to evaluate the client's respiratory status before making any adjustments to the oxygen therapy.

Choice D rationale:

"Evaluate the client's respiratory status" is the correct response. When a client with COPD and oxygen therapy reports difficulty breathing, the nurse's priority is to assess the client's respiratory status. This assessment will help determine the cause of the breathing difficulty and guide appropriate interventions. The nurse should also check the oxygen saturation levels, respiratory rate, and auscultate lung sounds to assess the severity of the issue.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer digoxin to a client who has left-sided heart failure.Which of the following clinical manifestations should the nurse expect to see in this client? (Select all that apply.).

Correct Answer is ["C","D","E"]

Explanation

A home health nurse is visiting a client who has COPD and is receiving oxygen at 2 L/min via nasal cannula.The client tells the nurse she has been having difficulty breathing.Which of the following actions is the nurse's priority at this time?

Correct Answer is D

Explanation

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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?

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?