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 C,A,B,D
Explanation
The correct sequence of steps for palpating a client's systolic blood pressure using brachial artery is as follows:
- Palpate brachial pulse site.
- Inflate blood pressure cuff to 30 mm Hg beyond where brachial pulse was last felt. - Deflate blood pressure cuff slowly until brachial pulse is detected.
- Discontinue palpation of brachial pulse.
Correct Answer is B
Explanation
A condom catheter is a urine collection device that fits like a condom over the penis and has a tube that goes to a collection bag strapped to the leg. To apply a condom catheter, the nurse should clean and dry the penis thoroughly, unroll the sheath over the penis, leaving 2.5 to 5 cm (1 to 2 in) of space between the end of the catheter and the tip ofthe penis, and gently squeeze the catheter around the penis shaft for 10 to 15 seconds to ensure adhesion.
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