A nurse hangs a bag of dextrose 5% in water, 1,000 mL at 0800 to run at 125 mL/hr. At 1200, the nurse notices that the client's IV bag is empty. Which of the following interventions should the nurse take first?

Notify the primary care provider.

Assess the client's vital signs.

Calculate the infused volume.

Complete an incident report.

Answer and Explanation

The Correct Answer is B

If a nurse hangs a bag of dextrose 5% in water, 1,000 mL at 0800 to run at 125 mL/hr and notices that the client's IV bag is empty at 1200, the first intervention the nurse should take is to assess the client's vital signs. This will help the nurse determine if the client is experiencing any adverse eﬀects from the rapid infusion of ﬂuids.

Option a is incorrect because notifying the primary care provider is important but not the first intervention.

Option c is incorrect because calculating the infused volume is important but not the first intervention.

Option d is incorrect because completing an incident report is important but not the first intervention.

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Correct Answer is B

Explanation

The correct answer is that the nurse should recommend the client to eat a light carbohydrate snack before bedtime. Eating a light carbohydrate snack before bedtime can help promote sleep by increasing the level of tryptophan in the brain, which can help induce sleep.

Options a, c and d are not appropriate interventions for insomnia. Taking a 30-min nap daily can disrupt nighttime sleep and worsen insomnia. Exercising 1 hr before bedtime can increase alertness and make it harder to fall asleep. Drinking a cup of hot cocoa before bedtime can also disrupt sleep due to its caﬀeine content.

A. Request a prescription for an indwelling urinary catheter. B. Arrange for an alternating pressure mattress. C. Apply cornstarch to the client's skin. D. Reposition the client every 4 hours.

Correct Answer is B

Explanation

An alternating pressure mattress can help prevent skin breakdown in a client who is immobile by redistributing pressure and reducing the risk of pressure ulcers. This is an appropriate action for the nurse to include in the plan of care for a client who is immobile and has urinary incontinence.

a. An indwelling urinary catheter can increase the risk of infection and should only be used when other methods of managing urinary incontinence are not eﬀective.

c. Cornstarch can absorb moisture and help keep the skin dry, but it is not recommended for use on broken skin or in areas where there is a risk of fungal infection.

d. Repositioning the client every 4 hours may not be frequent enough to prevent skin breakdown. The client should be repositioned at least every 2 hours to reduce the risk of pressure ulcers.

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A nurse hangs a bag of dextrose 5% in water, 1,000 mL at 0800 to run at 125 mL/hr. At 1200, the nurse notices that the client's IV bag is empty. Which of the following interventions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend?

Correct Answer is B

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A nurse is planning care to prevent skin breakdown for a client who is immobile and has urinary incontinence. Which of the following actions should the nurse include in the plan of care?

Correct Answer is B

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