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","D","E"]
Explanation
“I need to have a fire escape plan with my family,” “I will use the grab bars when getting in and out of the bathtub,” and “I need to check my medications for expiration dates” are all important home safety measures.
Choice A is wrong because setting the hot water heater to 140 degrees Fahrenheit is too high and can increase the risk of scalding.
The recommended temperature for a hot water heater is 120 degrees Fahrenheit.
Choice B is wrong because applying tape over frayed areas of electrical cords is not a safe solution.
Frayed electrical cords should be replaced to prevent electrical hazards.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today