During a shift change report, a nurse notices that a patient’s IV bag of 0.9% sodium chloride has 900 mL of fluid remaining.
The nurse checks again 30 minutes later and finds that the IV bag is empty. What should the nurse do in this situation?
Request NPO status for the client.
Elevate the head of the bed to high Fowler’s.
Measure the client’s temperature.
Check the client’s respiratory rate and lung sounds.
The Correct Answer is D
NPO status (nothing by mouth) is not a relevant intervention in this situation. It would be indicated for a patient with gastrointestinal issues or prior to a procedure, but it does not address the potential consequences of rapid fluid administration.
Restricting oral intake would not reverse or mitigate the effects of fluid overload that may have already occurred.
It's important to prioritize assessment of the patient's respiratory status, as fluid overload can lead to pulmonary edema, a serious complication.
Rationale for Choice B:
Elevating the head of the bed to high Fowler's position can be helpful in easing breathing for patients with respiratory distress, but it's not the most immediate priority in this case.
Assessing the patient's respiratory status directly through respiratory rate and lung sounds will provide more comprehensive information about potential fluid overload and guide further interventions.
Rationale for Choice C:
Measuring the client's temperature is not directly relevant to the concern of rapid fluid administration.
While fever could be a sign of infection, which might warrant fluid administration, it's not the primary concern in this scenario.
The priority is to assess for potential fluid overload, which could manifest as respiratory distress. Rationale for Choice D:
Checking the client's respiratory rate and lung sounds is the most appropriate action for the nurse to take in this situation.
Rapid infusion of 900 mL of fluid within a short period could lead to fluid overload, which can manifest as: Increased respiratory rate
Crackles in the lungs Shortness of breath Hypoxia
Early identification of these signs is crucial for prompt intervention and prevention of serious complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A: Refer questions to the nursing supervisor.
Choice A rationale: By referring inquiries from other nurses to the nursing supervisor, the nurse maintains patient privacy and upholds healthcare privacy regulations, such as the Health Insurance Portability and Accountability Act (HIPAA). These regulations mandate that patient information should only be disclosed on a need-to-know basis. Referring questions to the nursing supervisor ensures that any information released is managed through the appropriate channels and protects the patient's confidentiality.
Choice B rationale: Transferring calls directly to the patient's room could infringe on their privacy and disrupt their care or rest. It is not the nurse's role to decide if the patient should be disturbed, and doing so may potentially compromise patient care and satisfaction.
Choice C rationale: Acknowledging that the person is a patient on the unit can violate confidentiality rules, as it confirms the individual's presence in the hospital and could lead to speculation about their condition. Nurses must maintain patient privacy by refraining from sharing any information, even if it seems harmless.
Choice D rationale: Contacting the patient's provider does not directly address the issue of handling inquiries from other nurses and could breach confidentiality if the provider discloses information without the patient's consent. Additionally, the provider may not be immediately available, which would delay addressing the inquiries and potentially expose the patient's privacy further.
Correct Answer is B
Explanation
Choice A rationale:
Naloxone does not have any direct effect on respiratory secretions. It works by binding to opioid receptors in the brain and reversing the effects of opioids, such as respiratory depression.
While opioids can cause a decrease in respiratory secretions, this is not the primary reason for administering naloxone.
It is important to note that naloxone can actually worsen respiratory secretions in some patients, particularly those with chronic obstructive pulmonary disease (COPD) or other respiratory conditions.
Choice B rationale:
Naloxone is a medication that is specifically designed to block the effects of opioids on the central nervous system (CNS).
It is a competitive antagonist, which means that it binds to opioid receptors in the brain and prevents opioids from binding to those receptors.
This can reverse the effects of opioids, such as respiratory depression, sedation, and hypotension.
Naloxone is often used to treat opioid overdose, but it can also be used to prevent opioid-induced respiratory depression in patients who are receiving opioids for pain relief.
Choice C rationale:
Naloxone is not effective in treating nausea.
In fact, it can actually worsen nausea in some patients.
This is because naloxone can block the effects of opioids in the brain, and opioids can sometimes have a nausea-relieving effect.
Choice D rationale:
Naloxone is not effective in treating urinary retention.
Urinary retention is a common side effect of opioids, but it is not caused by the effects of opioids on the CNS. Urinary retention is typically caused by the effects of opioids on the bladder muscles.
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