A nurse is caring for a client who has a prescription for a 250 mL IV fluid bolus. The nurse administers a 500 mL IV bolus.
Which of the following actions should the nurse take first?
Obtain the client's vital signs.
Notify the healthcare provider.
Document the incident in the client’s medical record.
Assess the client for adverse reactions.
The Correct Answer is D
Notify the healthcare provider.
The nurse should first notify the healthcare provider of the error in administering the IV bolus.
This is important because the healthcare provider can assess the situation and provide guidance on how to proceed.
Choice A is not the correct answer because obtaining the client’s vital signs is important but not the first action the nurse should take.
Choice C is not the correct answer because documenting the incident in the client’s medical record is important but not the first action the nurse should take.
Choice D is not the correct answer because assessing the client for adverse reactions is important but not the first action the nurse should take.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
According to the Centers for Disease Control and Prevention (CDC), tuberculosis (TB) infection control plan is part of a general infection control program designed to ensure prompt detection of infectious TB patients, airborne precautions, and treatment of people who have suspected or confirmed TB disease.
Choice A, Contact precautions, are not necessary for TB patients as TB is not spread through contact.
Choice B, Protective precautions, are used to protect immunocompromised patients from infections and are not necessary for TB patients.
Choice C, Droplet precautions, are used for diseases that are spread through large respiratory droplets and are not necessary for TB patients as TB is spread through airborne droplet nuclei.
Correct Answer is D
Explanation
When a client is restrained to each extremity, it is important for the nurse to assess the client’s peripheral pulses first to ensure that circulation is not compromised.
Choice A, Elimination needs, is important but not the first priority in this situation.
Choice B, Comfort level, is also important but not the first priority in this situation.
Choice C, Skin integrity, is important but not the first priority in this situation.
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