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 C

Explanation

Choice A rationale:

"Fresh fruits are good to include with meals.”. Including fresh fruits with meals is an excellent choice for a heart-healthy diet. Fresh fruits are rich in essential vitamins, minerals, and fiber, which can help lower blood pressure and reduce the risk of heart disease.

Choice B rationale:

"I will replace table salt with dried herbs.”. This is a good choice for reducing sodium intake. Dried herbs can add flavor to food without the need for table salt, which is high in sodium. Lowering sodium intake is crucial for individuals with hypertension to manage their condition and maintain a heart-healthy diet.

Choice C rationale:

"I can have a cola drink twice a day.”. This choice is incorrect. Consuming cola drinks, which are high in sugar and caffeine, is not advisable for individuals with hypertension. High sugar intake can contribute to weight gain and high blood pressure, while caffeine can temporarily raise blood pressure. Clients with hypertension should limit or avoid soda consumption.

Choice D rationale:

"I can eat frozen juice bars for a snack.”. Frozen juice bars can be a healthier alternative to high-calorie, sugary snacks. However, the specific content of these bars should be considered. If they contain added sugars or high levels of sodium, it may not be the best choice. Clients with hypertension should focus on snacks that are low in added sugars and salt.

A. Discontinue the dose 2 weeks before surgery. B. Decrease the dose by half 2 weeks before surgery. C. Take the originally prescribed dose the week of surgery. D. Double the dose the week of surgery.

Correct Answer is A

Explanation

Choice A rationale:

The nurse should instruct the client to discontinue the dose of acetylsalicylic acid (aspirin) 2 weeks before surgery. Aspirin is an antiplatelet medication that can increase the risk of bleeding during and after surgery. Discontinuing it before surgery helps reduce the risk of excessive bleeding during the procedure. The recommended time frame for discontinuation may vary based on the patient's surgical procedure and the surgeon's preferences. However, 2 weeks is a common guideline to ensure that the antiplatelet effects of aspirin have diminished.

Choice B rationale:

Decreasing the dose by half 2 weeks before surgery may not be sufficient to minimize the risk of bleeding associated with aspirin. It is generally recommended to discontinue the medication completely to ensure that the antiplatelet effect has worn off.

Choice C rationale:

Taking the originally prescribed dose of aspirin the week of surgery is not advisable because it can increase the risk of bleeding during the surgical procedure. It is important to discontinue aspirin well before the surgery.

Choice D rationale:

Doubling the dose of aspirin the week of surgery is contraindicated as it can significantly increase the risk of bleeding. This choice is not recommended in the context of preoperative management.

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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 reinforcing teaching about a heart-healthy diet with a group of clients who have hypertension. Which of the following statements by the clients indicates a need for further teaching?

Correct Answer is C

Explanation

A nurse is conducting a preoperative interview with a client who is scheduled for surgery.The client states that he takes acetylsalicylic acid 81 mg. by mouth daily.Prior to the client's upcoming surgery, the nurse should instruct the client to do which of the following?

Correct Answer is A

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?