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.
Calculate the infused volume.
Complete an incident report.
Assess the client's vital signs.
The Correct Answer is D
The nurse should assess the client's vital signs first to determine if there are any signs of fluid overload, such as hypertension, edema, crackles, or dyspnea. The nurse should then notify the primary care provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
When caring for a client who has restraints, the nurse should follow the ABCDE priority-setting framework and assess airway, breathing, circulation, disability, and exposure first. Peripheral pulses are an indicator of circulation and should be assessed first to ensure adequate blood flow to the extremities. Comfort level, skin integrity, and elimination needs are also important assessments but are not as high priority as circulation.
Correct Answer is D
Explanation
The nurse should identify that discussing the client's transfer to a long-term care facility with a nurse from another unit is a violation of HIPAA because it is not related to the client's care or treatment. The nurse should only share information with health care team members who are directly involved in the client's care or have a legitimate need to know.
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