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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Correct Answer is D
Explanation
The correct answer is d. Unplug the pump.
Rationale for Choice A:
- While notifying the biomedical department to fix the pump is important,it is not the immediate priority in this situation.The first step is to ensure patient and staff safety by removing the potential electrical hazard.
- Delaying the removal of the sparking pump could lead to electrical shock,fire,or other serious consequences.
- Biomedical staff can be notified after the immediate safety risk has been addressed.
Rationale for Choice B:
- Obtaining a replacement pump is necessary to continue the client's IV therapy,but it is not the first action the nurse should take.
- The priority is to eliminate the electrical hazard posed by the sparking pump.
- Once the faulty pump is unplugged and safety is ensured,the nurse can then proceed to obtain a replacement pump.
Rationale for Choice C:
- Labeling the pump with a defective equipment sticker is important to prevent others from using it,but it does not address the immediate safety risk.
- The priority is to disconnect the pump from the power source to eliminate the risk of electrical shock or fire.
- Labeling can be done after the pump has been unplugged and the situation has been assessed.
Rationale for Choice D:
- Unplugging the pump is the correct first action because it immediately removes the electrical hazard,preventing potential harm to the patient,staff,or equipment.
- This action prioritizes safety and mitigates the risk of electrical shock,burns,fire,or other serious consequences.
- It is essential to act quickly and decisively in such situations to ensure a safe environment for everyone involved.
Correct Answer is D
Explanation
The nurse should place the extremity in a dependent position before inserting an IV catheter.
This helps to dilate the veins and make them more visible and easier to access.
Choice A is wrong because the nurse should choose a site that is distal to the most proximal site on the extremity selected.
This helps to preserve more proximal sites for future use if needed.
Choice B is wrong because applying a cool compress before insertion of an IV catheter can cause vasoconstriction and make it more difficult to access the vein.
Instead, a warm compress can be applied to help dilate the veins.
Choice C is wrong because the tourniquet should be placed above, not below, the proposed insertion site to help dilate the vein and make it easier to access.
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