Difficulty: Medium
Average Score: 92%
Simulated
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?
Correct answer
D
Rationale
Checking respiratory rate and lung sounds assesses for fluid overload from rapid infusion. NPO status, head elevation, and temperature measurement are less relevant.