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?

Rationale: A. Elevating the head of the bed is appropriate for respiratory distress, but the priority is to assess for signs of fluid overload. B. The IV infused 900 mL in just 30 minutes, which is a dangerously rapid rate and can lead to fluid volume overload, especially in vulnerable clients. The nurse should assess for signs such as increased respiratory rate and crackles in the lungs, indicating pulmonary edema. C. Measuring temperature is not the priority in this situation and does not relate directly to fluid overload. D. NPO status does not address the immediate concern of a rapid IV infusion and its potential consequences.