During a change-of-shirt 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?
Explanation & Rationale
A. Request NPO status for the client: Making the client NPO is unrelated to an unexpectedly empty IV bag and would not address potential complications from a rapid infusion. B. Elevate the head of the bed to high Fowler's: High Fowler’s can ease breathing if pulmonary edema or respiratory distress is present, but assessment should come first to determine need. C. Check the client's respiratory rate and lung sounds: A rapidly infused IV can cause fluid overload and pulmonary edema; assessing respiratory rate and lung sounds is the priority to detect early fluid overload or respiratory compromise. D. Measure the client's temperature: Temperature helps detect infection but is not the immediate concern when an IV has been infused unexpectedly fast.