During a change-of-shift report, a nurse sees that a client's IV bag of 0.9% sodium chloride has 900 mL of fluid left in it. The nurse makes rounds 30 minutes later and notes that the IV bag is empty.
Which of the following actions should the nurse take?

Check the client's respiratory rate and lung sounds.

Request NPO status for the client.

Elevate the head of the bed to high Fowler's.

Measure the client's temperature.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Check the client's respiratory rate and lung sounds When an IV bag is unexpectedly empty, it is important to assess the client for potential complications, especially if the client was receiving fluid therapy. Checking the respiratory rate and lung sounds is essential to ensure there are no signs of respiratory distress, such as crackles or wheezing, which could indicate fluid overload or a pulmonary issue.

Choice B rationale:

Request NPO status for the client Requesting nothing by mouth (NPO) status is not the immediate action required when an IV bag is empty. The priority is to assess the client's condition and address any potential issues first.

Choice C rationale:

Elevate the head of the bed to high Fowler's Elevating the head of the bed to high Fowler's is a measure to assist with preventing aspiration during oral intake. It is not the primary action required in this situation, where assessing the client's respiratory and fluid status is more important.

Choice D rationale:

Measure the client's temperature Measuring the client's temperature is not the immediate priority in this scenario. Assessing the client's respiratory and fluid status is more critical to identify any potential issues associated with the empty IV bag. .

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Correct Answer is A

Explanation

The correct answer is Choice A: Dull, aching calf pain.

Choice A rationale:

Dull, aching calf pain is a common symptom of deep vein thrombosis (DVT), which can occur postoperatively, especially after vascular surgery. This pain is often due to a blood clot forming in the deep veins of the leg.

Choice B rationale:

Positive Kernig's sign is associated with meningitis and not typically related to thrombus formation.

Choice C rationale:

Soft, pliable calf muscle is not indicative of a thrombus. A thrombus would more likely cause tenderness and swelling.

Choice D rationale:

Positive Homan's sign (pain in the calf upon dorsiflexion of the foot) can be an indicator of DVT, but it is less reliable than dull, aching calf pain.

A. Administer the medication with each meal. B. Have suction equipment at the bedside. C. Monitor the client for black, tarry stools. D. Initiate contact precautions.

Correct Answer is C

Explanation

The correct answer is choice C. Monitor the client for black, tarry stools.

Choice A rationale:

Administering clopidogrel with each meal is not necessary. Clopidogrel can be taken with or without food. The primary concern with clopidogrel is its potential to cause bleeding, so monitoring for signs of bleeding is more critical.

Choice B rationale:

Having suction equipment at the bedside is not specifically required for clients taking clopidogrel. This action is more relevant for clients at risk of airway obstruction or those undergoing procedures that might require suctioning.

Choice C rationale:

Monitoring the client for black, tarry stools is essential because it can indicate gastrointestinal bleeding, a known side effect of clopidogrel. This medication increases the risk of bleeding, so observing for signs of internal bleeding, such as melena (black, tarry stools), is crucial.

Choice D rationale:

Initiating contact precautions is not necessary for clients taking clopidogrel. Contact precautions are typically used to prevent the spread of infections, not for managing clients on antiplatelet therapy.

By understanding these rationales, the nurse can ensure the safe administration and monitoring of clopidogrel therapy.

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During a change-of-shift report, a nurse sees that a client's IV bag of 0.9% sodium chloride has 900 mL of fluid left in it. The nurse makes rounds 30 minutes later and notes that the IV bag is empty.Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following vascular surgery. Which of the following manifestations should indicate to the nurse that the client has developed a thrombus?

Correct Answer is A

Explanation

A nurse is caring for a client who has a prescription for clopidogrel. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

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During a change-of-shift report, a nurse sees that a client's IV bag of 0.9% sodium chloride has 900 mL of fluid left in it. The nurse makes rounds 30 minutes later and notes that the IV bag is empty.Which of the following actions should the nurse take?

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During a change-of-shift report, a nurse sees that a client's IV bag of 0.9% sodium chloride has 900 mL of fluid left in it. The nurse makes rounds 30 minutes later and notes that the IV bag is empty.
Which of the following actions should the nurse take?