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.

Answer and Explanation

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.

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Correct Answer is ["A","B","E","F"]

Explanation

Choice A rationale:

Temperature control for either hypothermia or hyperthermia is crucial in septic shock management. Here's a detailed explanation:

Hypothermia:

Mechanism: Septic shock often causes impaired thermoregulation, leading to hypothermia. It can worsen shock by decreasing cardiac output, impairing coagulation, and promoting vasoconstriction.

Intervention: Active warming measures are essential, including: External warming devices (e.g., blankets, forced air warmers) Intravenous fluids warmed to 39-42°C

Warmed humidified oxygen

Minimizing exposure and covering the patient Hyperthermia:

Mechanism: Sepsis can trigger an excessive inflammatory response, leading to hyperthermia. It can exacerbate tissue injury, increase metabolic demands, and worsen organ dysfunction.

Intervention: Aggressive measures to lower temperature are necessary, including:

Antipyretic medications (e.g., acetaminophen, ibuprofen) External cooling methods (e.g., cooling blankets, ice packs) Sedation if shivering occurs

Choice B rationale:

Administration of cardiotonic agents such as dopamine, dobutamine, or norepinephrine is often required in septic shock to: Improve cardiac output: These agents increase myocardial contractility and heart rate, enhancing blood flow to vital organs.

Maintain blood pressure: They support vasoconstriction, counteracting the widespread vasodilation characteristic of septic shock.

Improve tissue perfusion: By optimizing cardiac output and blood pressure, they help ensure adequate oxygen and nutrient delivery to tissues.

Choice E rationale:

Blood cultures from all suspected sources before administration of antibiotics are essential for guiding appropriate antibiotic therapy.

Early identification of the causative organism: This information is crucial for selecting the most effective antibiotic regimen.

Prevention of antibiotic resistance: Judicious use of antibiotics based on culture results helps prevent the development of antibiotic-resistant bacteria.

Choice F rationale:

Vigorous intravenous fluid resuscitation with 0.9% sodium chloride is a cornerstone of septic shock management.

Replenishing intravascular volume: Septic shock often causes profound intravascular volume depletion due to capillary leak and vasodilation. Fluid resuscitation aims to restore circulating volume and maintain organ perfusion.

Improving hemodynamic stability: By increasing preload and cardiac output, fluids help stabilize blood pressure and support vital organ function.

A. Administer a prescribed analgesic. B. Check the patency of the tubing. C. Notify the provider. D. Offer oral fluids.

Correct Answer is B

Explanation

Choice B rationale:

Checking the patency of the tubing is the first and most crucial step in addressing the lack of urinary output in this patient. Here's a detailed explanation of why this is the priority action:

Addresses the Most Likely Cause: Obstruction of the urinary catheter tubing is the most common and easily reversible cause of sudden cessation of urinary output in a patient with a continuous bladder irrigation system.

Prevents Complications: A blocked catheter can lead to a number of serious complications, including: Bladder distention, which can cause pain, discomfort, and potential bladder damage.

Urinary retention, which can increase the risk of urinary tract infections (UTIs) and kidney damage. Hematuria, or blood in the urine, due to clot formation in the bladder or catheter.

Non-Invasive Intervention: Checking the tubing is a simple, non-invasive procedure that can quickly identify and resolve the issue without requiring further interventions or delays in care.

Prioritizes Patient Safety: It's essential to promptly address any potential urinary obstruction to prevent the aforementioned complications and ensure patient safety.

Rationale for Other Choices:

Choice A: Administering a prescribed analgesic:

While pain management is important, it does not directly address the lack of urinary output. Pain medication would be appropriate if pain were assessed to be the cause of the decreased output, but it's not the first priority in this situation.

Choice C: Notifying the provider:

Although the provider should be informed of the situation, checking the tubing for patency is a necessary first step to gather more information and potentially resolve the issue quickly without requiring further intervention.

Choice D: Offering oral fluids:

Increasing fluid intake might be helpful in some cases of decreased urinary output, but it's not the priority action in a patient with a continuous bladder irrigation system and a potential catheter obstruction.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient has been diagnosed with septic shock.What collaborative interventions would be expected? (Select all that apply)

Correct Answer is ["A","B","E","F"]

Explanation

A nurse is looking after a patient who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation.The nurse observes that there has been no urinary output in the last hour. What should the nurse do first?

Correct Answer is B

Explanation

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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?