A nurse is assisting in the care of a client receiving IV fluids. The nurse identifies that the IV pump has been infusing the fluids at double the rate of the prescribed order. After stopping the infusion, which of the following actions is the nurse's priority?

Notify the unit manager.

Collect data on the client.

Notify the provider.

Complete an incident report.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Notify the unit manager: Informing the unit manager is necessary for institutional follow-up and quality assurance. However, it is not the immediate concern. Client safety and clinical status must be assessed first to determine if harm has occurred due to the error.

B. Collect data on the client: Assessing the client is the priority to determine if the excessive fluid has caused complications such as fluid overload, pulmonary edema, or changes in vital signs. Early identification of adverse effects is essential to guide further intervention.

C. Notify the provider: The provider should be informed after assessing the client so that appropriate medical interventions or monitoring can be initiated. Immediate data collection ensures the nurse can give accurate information about the client’s status.

D. Complete an incident report: Documentation of the error is an important step for institutional learning and accountability. However, it is not time-sensitive in the way client safety and assessment are and should follow after urgent clinical actions are taken.

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Correct Answer is A

Explanation

Rationale:

A. Place a towel in the sink when cleaning the dentures: Lining the sink with a towel or filling it partially with water provides a cushion to prevent the dentures from breaking if accidentally dropped during cleaning. This is a key safety step in proper denture care.

B. Remove the lower dentures before the upper dentures: Upper dentures should be removed first because they are usually looser and easier to dislodge. Removing the lower dentures first increases the risk of damaging the upper set or causing discomfort to the client.

C. Store the dentures in a dry denture cup on the bedside table after cleaning: Dentures should always be stored in water or a denture-cleaning solution when not in use to prevent warping. Leaving them dry can cause them to crack, lose their shape and may increase contamination risk.

D. Use a circular motion to cleanse the biting surface of the dentures: Denture cleaning requires gentle scrubbing using vertical or back-and-forth strokes rather than circular motions, to effectively remove debris and avoid damaging the prosthetic structure.

A. Oxytocin B. Misoprostol C. Magnesium sulfate D. Indomethacin

Correct Answer is C

Explanation

Rationale:

A. Oxytocin: Oxytocin is a uterotonic agent used to stimulate or augment labor, not to stop it. In the case of preterm labor at 36 weeks, administering oxytocin would worsen the situation by increasing uterine contractions and promoting delivery, which is not the intended goal.

B. Misoprostol: Misoprostol is typically used to induce labor by softening the cervix and stimulating contractions. It is contraindicated in clients experiencing preterm labor, as it would enhance uterine activity and could lead to premature delivery.

C. Magnesium sulfate: Magnesium sulfate is used in preterm labor to provide neuroprotection to the fetus and may also help reduce uterine contractions. It is especially indicated when labor is expected before 32–34 weeks but may still be prescribed at 36 weeks depending on clinical judgment.

D. Indomethacin: Indomethacin is a tocolytic agent used to suppress preterm labor contractions, but it is generally used before 32 weeks due to the risk of premature closure of the ductus arteriosus. At 36 weeks, the risks may outweigh the benefits, so it is not the first-line option at this gestational age.

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A nurse is assisting in the care of a client receiving IV fluids. The nurse identifies that the IV pump has been infusing the fluids at double the rate of the prescribed order. After stopping the infusion, which of the following actions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is unable to perform ADLS and wears dentures. Which of the following actions should the nurse take when providing denture care?

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Explanation

A nurse is assisting in the care of a client who is at 36 weeks of gestation and is in preterm labor. The nurse should expect a prescription for which of the following medications for the client?

Correct Answer is C

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