During a shift change report, a nurse notices that a patient’s IV bag of 0.9% sodium chloride has 900 mL of fluid remaining.
The nurse checks again 30 minutes later and finds that the IV bag is empty. What should the nurse do in this situation?

Request NPO status for the client.

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

Measure the client’s temperature.

Check the client’s respiratory rate and lung sounds.

Answer and Explanation

The Correct Answer is D

NPO status (nothing by mouth) is not a relevant intervention in this situation. It would be indicated for a patient with gastrointestinal issues or prior to a procedure, but it does not address the potential consequences of rapid fluid administration.

Restricting oral intake would not reverse or mitigate the effects of fluid overload that may have already occurred.

It's important to prioritize assessment of the patient's respiratory status, as fluid overload can lead to pulmonary edema, a serious complication.

Rationale for Choice B:

Elevating the head of the bed to high Fowler's position can be helpful in easing breathing for patients with respiratory distress, but it's not the most immediate priority in this case.

Assessing the patient's respiratory status directly through respiratory rate and lung sounds will provide more comprehensive information about potential fluid overload and guide further interventions.

Rationale for Choice C:

Measuring the client's temperature is not directly relevant to the concern of rapid fluid administration.

While fever could be a sign of infection, which might warrant fluid administration, it's not the primary concern in this scenario.

The priority is to assess for potential fluid overload, which could manifest as respiratory distress. Rationale for Choice D:

Checking the client's respiratory rate and lung sounds is the most appropriate action for the nurse to take in this situation.

Rapid infusion of 900 mL of fluid within a short period could lead to fluid overload, which can manifest as: Increased respiratory rate

Crackles in the lungs Shortness of breath Hypoxia

Early identification of these signs is crucial for prompt intervention and prevention of serious complications.

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Correct Answer is A

Explanation

Choice A rationale:

Painful urination (dysuria) can be a sign of several conditions that could potentially affect the client's IVP or indicate a need for further assessment. These conditions include:

Urinary tract infection (UTI): UTIs are common in clients with recurrent kidney stones, and they can cause inflammation and pain in the urinary tract. If a client has a UTI, it's important to treat it before the IVP to reduce the risk of spreading the infection to the kidneys.

Kidney stone passage: The client's history of kidney stones makes it possible that the pain could be due to the passage of a stone. This would be important information for the healthcare team to know, as it could affect the interpretation of the IVP results.

Other urological conditions: There are other urological conditions, such as bladder or urethral strictures, that can also cause painful urination. These conditions might also need to be considered and assessed for.

It's important for the nurse to collect more data about the client's painful urination to determine the underlying cause and whether it could impact the IVP. This might include asking questions about:

The severity and duration of the pain

Any other associated symptoms, such as fever, urgency, or frequency The client's history of UTIs or kidney stones

Any recent changes in urinary habits

Based on this additional information, the nurse can then collaborate with the healthcare team to determine the best course of action, which might include:

Further assessment, such as a urinalysis or urine culture Treatment for a UTI, if present

Pain management

Rescheduling the IVP, if necessary

A. “Okay then; let me know if you need anything.” B. “That is not bad. C. “I understand you have had the pain for a while. Let’s investigate this further.” D. you know what might be causing the pain?” L. t me know if your pain becomes greater than 4 out of 10; then we can treat it.”

Correct Answer is C

Explanation

Choice A rationale:

This response is dismissive of the patient's pain and does not offer any assistance. It also does not acknowledge the patient's concerns about their pain being a normal part of aging.

It's important to validate the patient's experience and offer support, even if the pain level is not severe.

This response could lead to the patient feeling unheard and unsupported, and it could potentially delay necessary treatment.

Choice B rationale:

This response suggests that the patient's pain is not significant enough to warrant treatment unless it worsens. This is not appropriate, as pain is subjective and should be treated based on the patient's individual experience.

Additionally, this response reinforces the patient's belief that pain is a normal part of aging, which may prevent them from seeking treatment in the future.

Choice C rationale:

This response is the best option because it acknowledges the patient's pain, expresses concern, and suggests further investigation.

It is important to rule out any underlying medical conditions that may be causing the pain.

This response also demonstrates to the patient that the nurse is taking their pain seriously and is committed to helping them manage it.

Choice D rationale:

This response acknowledges that pain can be a part of aging, but it also suggests that there may be a specific cause for the patient's pain.

This could lead to the patient feeling anxious or worried about their health.

It is important to investigate the cause of the pain before making any assumptions.

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During a shift change report, a nurse notices that a patient’s IV bag of 0.9% sodium chloride has 900 mL of fluid remaining.The nurse checks again 30 minutes later and finds that the IV bag is empty. What should the nurse do in this situation?

Nursing Test Bank

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Explanation

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During a shift change report, a nurse notices that a patient’s IV bag of 0.9% sodium chloride has 900 mL of fluid remaining.
The nurse checks again 30 minutes later and finds that the IV bag is empty. What should the nurse do in this situation?