A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 2560 1500. The nurse making rounds at 1545 finds that the client is complaining of a pounding headache and is dyspneic, experiencing chills, and a
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A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 2560 1500. The nurse making rounds at 1545 finds that the client is complaining of a pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action first? 1. Slow the IV infusion. 2. Sit the client up in bed. 3. Remove the IV catheter. 4. Call the primary health care provider (PHCP).Packed red blood cells have been prescribed for a female client with anemia who has a hemoglobin level of 7.6 g/dL (76 mmol/L) and a hematocrit level of 30% (0.30). The nurse takes the client’s temperature before hanging the blood transfusion and records 100.6° F (38.1° C) orally. Which action should the nurse take? 1. Begin the transfusion as prescribed. 2. Administer an antihistamine and begin the transfusion. 3. Administer 2 tablets of acetaminophen and begin the transfusion. 4. Delay hanging the blood and notify the primary health care provider (PHCP).The nurse is caring for a client experiencing acute lower gastrointestinal bleeding. In developing the plan of care, which priority problem should the nurse assign to this client? 1. Deficient fluid volume related to acute blood loss 2. Risk for aspiration related to acute bleeding in the GI tract 3. Risk for infection related to acute disease process and medications 4. Imbalanced nutrition, less than body requirements, related to lack of nutrients and increased metabolismThe nurse is assessing the functioning of a chest tube drainage system in a client with a chest injury who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply. 1. Excessive bubbling in the water seal chamber 2. Vigorous bubbling in the suction control chamber 3. Drainage system maintained below the client’s chest 4. 50 mL of drainage in the drainage collection chamber 5. Occlusive dressing in place over the chest tube insertion site 6. Fluctuation of water in the tube in the water seal chamber
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