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 B

Explanation

Choice A rationale:

Tenderness to touch is a common finding in wounds healing by secondary intention. It's often due to inflammation, which is a normal part of the healing process. The inflammation brings in cells and substances that promote healing. However, increased tenderness, especially when accompanied by other signs of infection, should be reported.

Choice B rationale:

A halo of erythema on the surrounding skin is a sign of infection. This is a serious complication that can delay healing and lead to further complications. The erythema indicates that the infection is spreading beyond the wound edges and needs prompt attention.

Choice C rationale:

Drainage of serosanguineous fluid is also common in wounds healing by secondary intention. This fluid is a mixture of serum (clear yellowish fluid) and blood. It's a sign that the wound is cleaning itself and new tissue is forming. While excessive drainage or a change in color or odor could signal a problem, drainage itself is not necessarily a cause for concern.

Choice D rationale:

Pink, shiny tissue with a granular appearance is a sign of healthy granulation tissue. This is a type of tissue that forms during the healing process. It's rich in blood vessels and collagen, which are essential for wound healing. The presence of granulation tissue indicates that the wound is healing well.

A. A patient with a colostomy. B. A patient with an ileostomy. C. A patient receiving enteral feedings through an NG tube. D. A patient who has a chest tube following a motor vehicle crash.

Correct Answer is C

Explanation

Choice A rationale:

A colostomy is a surgical procedure that creates an opening in the colon (large intestine) to divert stool through the abdomen. While a colostomy can affect bowel function, it does not directly increase the risk of aspiration. This is because the colon is located further down the digestive tract and does not directly involve the airway.

Choice B rationale:

An ileostomy is a surgical procedure that creates an opening in the ileum (small intestine) to divert stool through the abdomen. Similar to a colostomy, an ileostomy does not directly increase the risk of aspiration because the ileum is also located further down the digestive tract and does not involve the airway.

Choice C rationale:

Enteral feedings, also known as tube feedings, involve delivering nutrients directly into the stomach or small intestine through a tube. Patients receiving enteral feedings through a nasogastric (NG) tube are at a significantly higher risk of aspiration for several reasons:

Impaired swallowing mechanisms: Many patients who require enteral feedings have impaired swallowing mechanisms, which can increase the risk of food or liquid entering the airway instead of the esophagus.

Tube placement: The NG tube itself can potentially irritate the esophagus or interfere with the normal closure of the upper esophageal sphincter, which can increase the risk of reflux and aspiration.

Feeding formula: Enteral feeding formulas are often thin and liquid-like, which can make them easier to aspirate than thicker liquids or solid foods.

Positioning: Patients receiving enteral feedings are often in a reclined position, which can make it easier for fluids to travel back up the esophagus and into the airway.

Choice D rationale:

A chest tube is a drainage tube inserted into the chest cavity to remove air or fluid. While a chest tube can affect respiratory function, it does not directly increase the risk of aspiration. This is because the chest tube drains fluid from the pleural space, which surrounds the lungs, and does not directly involve the airway or digestive tract.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a patient with a surgical wound healing by secondary intention. Which finding should the nurse report to the charge nurse?

Correct Answer is B

Explanation

A nurse is providing care to a group of patients in an adult medical-surgical unit. Which patient should the nurse identify as having the highest risk for aspiration?

Correct Answer is C

Explanation

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A nurse is caring for a group of patients on an adult medical-surgical unit.Which patient should the nurse identify as having the highest risk for aspiration?

A nurse is attending to a patient with a bowel obstruction who has been prescribed a nasogastric tube. What steps should the nurse take during the insertion of the nasogastric tube?

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A nurse is caring for a client who is postoperative and requesting something to drink. The nurse reads the client’s postoperative prescriptions, which include, “Clear liquids, advance diet as tolerated.” What action should the nurse take first?

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?

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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?