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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The Weber test is a screening test for hearing performed with a tuning fork that can detect unilateral conductive hearing loss and unilateral sensorineural hearing loss.
To perform Weber’s test, strike the fork against your knee or elbow, then place the base of the fork in the midline, high on the patient’s forehead.
Choice A is wrong because delivering a series of high-pitched sounds at random intervals is not part of Weber’s test.
Choice B is wrong because holding an activated tuning fork against the client’s mastoid process is part of Rinne’s test, not Weber’s test.
Choice D is wrong because whispering a series of words softly into one ear is not part of Weber’s test.
Correct Answer is C
Explanation
This statement indicates that the client will be provided with information about advance directives before making a decision.
Advance directives are legal documents that allow individuals to communicate their wishes for medical treatment in the event that they are unable to make decisions for themselves.
Choice A is wrong because signing advance directives is not a requirement for undergoing surgery.
Choice B is wrong because the provider does not need to sign the advance directives.
Choice D is wrong because the presence of a partner is not required when signing advance directives.
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