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 min later and notes that the IV bag is empty. Which of the following actions should the nurse take?

Choice A rationale The client received 900 mL of fluid over 30 minutes, which is a massive fluid volume overload at a rate of 1,800 mL/hr. Checking the client's respiratory rate and lung sounds is the priority because the rapid infusion significantly increases the circulating blood volume, potentially causing acute pulmonary edema. An increased respiratory rate, dyspnea, and crackles (rales) are key clinical indicators of this life-threatening complication, requiring immediate intervention. Choice B rationale While elevating the head of the bed to high Fowler's position can improve ventilation and ease breathing by decreasing venous return and lung congestion, the priority action is assessment. Without a prompt assessment of respiratory status, the nurse cannot confirm the presence and severity of pulmonary complications or initiate the necessary treatment like diuretics and oxygen. Choice C rationale Measuring the client's temperature is not the priority action in this scenario. A rapid infusion of 0.9% sodium chloride is primarily a cardiovascular and pulmonary risk. While an infusion could potentially cause a slight temperature change, the immediate and most critical threat to the client's stability is the risk of fluid overload and resulting acute congestive heart failure or pulmonary edema, which are assessed via respiratory and cardiac parameters. Choice D rationale Requesting NPO (Nothing by Mouth) status is primarily relevant for preventing aspiration in situations like impending surgery or altered consciousness. It is not a direct intervention for the acute, life-threatening risk of pulmonary edema caused by the rapid intravenous fluid infusion. The priority must focus on correcting the hemodynamic and respiratory consequences of the massive fluid bolus.