A nurse in a health clinic is caring for a client. Click to highlight the findings that the nurse should report to the provider. To deselect a finding, click on the finding again.

Nurse's Notes

0930:

• Client reports 2-day history of urinary frequency, burning on urination, and lower back and suprapubic pain. States developed a fever of 39.3°C (102.8°F) this morning.
• Oriented x-4, answers questions appropriately.
• S1, S2, on auscultation. Lungs clear on auscultation.
• Bowel sounds x 4 quadrants active, denies nausea or vomiting.

0945:

• Request client provide clean-catch urinary specimen for testing.
• Urinalysis results reviewed.

Vital Signs 0930:

• Temperature: 39.3°C (102.8°F)
• Heart rate: 113/min
• Respiratory rate: 24/min
• Blood pressure: 122/68 mm Hg
• Oxygen saturation: 96% on room air

Diagnostic Results 1030:

Urinalysis

• Appearance: Cloudy
• Color: Amber yellow
• Odor: Aromatic
• pH: 8.0 (Reference: 4.6 to 8.0)
• Protein: 6.5 mg/dL (Reference: 0 to 8 mg/dL)
• Specific gravity: 1.035 (Reference: 1.005 to 1.030)
• Leukocyte esterase: Positive
• Nitrites: Present
• Ketones: None
• Bilirubin: None

Choice A reason:
Documenting the fluid infusion in the client's chart: While documenting the fluid infusion is important, assessing the client's vital signs should take priority to ensure their immediate safety and well-being.
Choice B reason:
Completing an incident report is incorrect Completing an incident report is a necessary step to document the error and initiate appropriate follow-up actions, but it should come after assessing the client's condition.
Choice C reason
Obtaining the client's vital signs is the correct answer. The correct first action for the nurse to take in this situation is to obtain the client's vital signs. Administering an excessive amount of IV fluid could potentially have adverse effects on the client's cardiovascular system, including fluid overload, electrolyte imbalances, and changes in blood pressure. Monitoring the client's vital signs will help assess their current condition and any potential complications resulting from the excess fluid administration.
Choice D reason
Reporting the incident to the unit manager is incorrect. Reporting the incident to the unit manager is important for organizational awareness and accountability, but the nurse's first responsibility is to assess the client's vital signs and address any potential complications.

Choice A reason:
Discarding the needle in a puncture-proof container is the correct action to be taken. After administering an injection, the nurse should immediately dispose of the needle in a puncture-proof container. This helps prevent needlestick injuries and ensures proper disposal of sharp objects.
Choice B reason:
Removing the needle from the syringe is inappropriate because it could increase the risk of a needlestick injury. Needles should be discarded as a unit with the syringe.
Choice C reason:
Placing the needle on the bedside table is not a safe practice and can lead to accidental needlestick injuries.
Choice D reason:
Recapping the needle before disposal is not recommended, as it increases the risk of needlestick injuries. Many healthcare organizations discourage recapping due to the potential for accidental needle sticks. If recapping is required by local policy, it should be done using a safe method.