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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. "I should do aerobic exercises once per day.": While exercise is beneficial for clients with COPD, it should be individualized and not necessarily done daily, especially in the beginning. Overexertion can worsen symptoms, so gradual and well-monitored activity is recommended.
B. "I will increase my fluid intake to 1,700 milliliters per day.": Clients with COPD are typically encouraged to consume 2,000 to 2,500 mL of fluids daily unless contraindicated. Higher fluid intake helps thin secretions, making them easier to expectorate and improving airway clearance.
C. "I should practice pursed-lip breathing exercises.": Pursed-lip breathing improves ventilation by keeping airways open longer during exhalation, reducing air trapping and dyspnea. It is a fundamental breathing technique taught to clients with COPD to improve oxygenation and control shortness of breath.
D. "I will consume low-protein, low-calorie foods.": Clients with COPD often have increased energy demands due to the work of breathing. A high-protein, high-calorie diet is typically recommended to prevent muscle wasting and support respiratory muscle strength.
Correct Answer is D
Explanation
Rationale:
A. "We only have to tell your parents if your test comes back positive.": Giving conditional privacy based on test results is misleading. Confidentiality in STI testing applies regardless of the outcome and is protected by law in many regions for adolescents.
B. "We need your parents' permission if you are on their insurance.": Insurance coverage does not determine the legal right to consent. While explanation of benefits forms may create confidentiality challenges, consent laws usually allow minors to access STI testing independently.
C. "We will have to get your parents' consent before testing you for STIs.": Requiring parental consent for STI testing contradicts legal protections in many areas that allow minors to access sexual and reproductive health care without parental involvement.
D. “We can test you for STIs without informing your parents.": Supporting the adolescent's autonomy and legal rights, this answer provides accurate information about confidential care and encourages open, respectful communication between the nurse and client.
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