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 B rationale:

Phlebitis is the inflammation of a vein, often caused by an IV catheter. It's characterized by redness, swelling, warmth, and pain along the vein.

Promptly discontinuing the IV infusion is crucial to prevent further irritation and potential complications such as: Thrombophlebitis (inflammation with clot formation)

Infection

Infiltration (leakage of fluids into surrounding tissues) Extravasation (leakage of vesicant or damaging medications)

Continuing the infusion could exacerbate the inflammation and increase the risk of these complications.

Choice A rationale:

Elevation of the extremity can help reduce swelling, but it does not address the underlying inflammation. It's often used as an adjunct measure after discontinuing the IV.

Choice C rationale:

Warm, moist compresses can provide some comfort and potentially promote blood flow, but they are not recommended as a first-line treatment for phlebitis. They may even worsen inflammation in some cases.

Choice D rationale:

Inserting an IV catheter in the opposite extremity is necessary if the patient still requires IV therapy, but it should not be done before addressing the phlebitis in the current site. This could lead to multiple sites of inflammation and increased risk of complications.

A. Chronic pain could cause restlessness, pacing, grimacing, and other facial expressions of pain. B. Chronic pain is limited and short in duration. C. A patient with chronic pain may have physical signs of tissue injury. D. Chronic pain may not manifest in a change of vital signs.

Correct Answer is A

Explanation

Choice A rationale:

Chronic pain can manifest in various behavioral and physical symptoms, including restlessness, pacing, grimacing, and other facial expressions of pain. These behaviors are often unconscious attempts to cope with or distract from the pain.

They may also reflect the emotional distress that often accompanies chronic pain. Patients may feel frustrated, anxious, or even depressed due to the persistent nature of their pain and its impact on their lives.

It's crucial for nurses to recognize these behavioral signs of pain, as patients may not always readily report their pain verbally. By observing these behaviors, nurses can assess the patient's pain level more accurately and provide appropriate interventions.

Choice B rationale:

Chronic pain is defined as pain that persists for longer than three months, often for much longer. It is not limited and short in duration.

This distinguishes it from acute pain, which is typically associated with an injury or illness and resolves within a few days or weeks.

Choice C rationale:

While some patients with chronic pain may have physical signs of tissue injury, this is not always the case. Chronic pain can also be caused by nerve damage, inflammation, or changes in the central nervous system.

In some cases, the underlying cause of chronic pain may be unknown.

Choice D rationale:

Although chronic pain may not always cause a significant change in vital signs, it can still be a very real and debilitating experience for patients.

Vital signs, such as heart rate, blood pressure, and respiratory rate, are often more sensitive to acute pain.

Nurses should not rely solely on vital signs to assess chronic pain. Instead, they should consider the patient's self-report of pain, behavioral cues, and other factors.

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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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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?