Evolve HESI Practice Exam

After 3 days of being NPO, what is the most important action for the nurse to take regarding a client receiving IV fluids?

1. Contact the physician for further orders

2. Adjust the IV rate to increase fluid delivery

3. Document in the medical record that these normal findings are expected outcomes

4. Prepare to perform a fluid challenge

The correct answer is: Document in the medical record that these normal findings are expected outcomes

The most important action for the nurse to take regarding a client who has been NPO (nothing by mouth) for three days and is receiving IV fluids is to document in the medical record that the normal findings are expected outcomes. This action is critical because thorough documentation serves several purposes in patient care. It communicates to other healthcare providers the rationale for the ongoing IV fluid administration and confirms that the patient's condition is being monitored appropriately. When a client is NPO, especially for an extended period, it is essential to document the response to IV fluid therapy, as this can include assessing hydration levels, nutrient delivery, and the overall status of the patient. By recording expected outcomes, it supports continuity of care and provides a clear history of the patient's condition and treatment plan. Understanding the context, normal findings in this scenario might relate to vital signs, fluid balance, and other clinical observations that assure the healthcare team that the patient is stable. Documentation is a fundamental aspect of the nursing process that enhances patient safety and facilitates effective communication. This approach does not involve immediate changes in treatment, such as adjusting IV rates or preparing for interventions that are not warranted without a doctor's order. Thus, documentation is not just an administrative task; it's a critical part of ensuring that all healthcare