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 A

Explanation

If a nurse is caring for an older adult client who tells the nurse that they have smoked one pack of cigarettes every day for the last 60 years, the next action the nurse should take is to ask what the client knows about the eﬀects of smoking. This will help the nurse assess the client's knowledge and understanding of the risks associated with smoking and provide an opportunity for education.

Option b is incorrect because working with the client to establish a quit date is important but not the next intervention.

Option c is incorrect because suggesting that the client use nicotine gum to facilitate quitting is important but not the next intervention.

Option d is incorrect because referring the client to a local smoking cessation program is important but not the next intervention.

A. The client's room number B. The client's admitting diagnosis C. The name of the client's next of kin D. The client's telephone number

Correct Answer is D

Explanation

The nurse should plan to use the client's telephone number to confirm their identity. This is because the telephone number is a unique identifier that is directly associated with the client and can be easily verified. By comparing the client's telephone number with the information on the medication administration record or electronic health record, the nurse can ensure that the right medication is given to the right patient.
Explanation:
a) The client's room number is not a reliable method to confirm the client's identity because multiple clients may be assigned to the same room, and there is a possibility of room changes or transfers.
b) The client's admitting diagnosis is not a suitable method to confirm identity as it does not provide specific information about the individual patient.
c) The name of the client's next of kin is not a reliable method to confirm the client's identity as it refers to a family member or emergency contact, not the client themselves. Additionally, next of kin information may not always be up to date or readily available.

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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 an older adult client who tells the nurse, "I have smoked one pack of cigarettes every day for the last 60 years." Which of the following actions should the nurse take next?

Correct Answer is A

Explanation

A nurse is preparing to administer several medications to a client. Which of the following data should the nurse plan to use to confirm the client's identity?

Correct Answer is D

Explanation

A nurse is preparing to administer a controlled substance to a client for pain management. Which of the following actions should the nurse take?

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A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?

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A nurse is performing a skin assessment on an older adult client. Which of the following findings should the nurse expect?

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