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 nurse should use the abbreviation “BRP” for bathroom privileges.
This is a commonly accepted abbreviation in the medical field and is used to indicate that a client has permission to use the bathroom.
Choice A is not the correct answer because “SC” is not a commonly accepted abbreviation for subcutaneous.
Instead, “SQ” or “SubQ” are more commonly used.
Choice B is not the correct answer because “SS” is not a commonly accepted abbreviation for sliding scale.
Instead, “Sliding Scale” should be written out in full to avoid confusion.
Choice D is not the correct answer because “OJ” is not a commonly accepted medical abbreviation for orange juice.
Instead, “orange juice” should be written out in full to avoid confusion.
Correct Answer is C
Explanation
If a client expresses confusion or lack of understanding about a medical procedure, the nurse should notify the provider so that they can clarify any misunderstandings and ensure that the client is fully informed before giving their consent.
Choice A is wrong because providing brochures about the procedure may not be sufficient to address the client’s confusion or lack of understanding.
Choice B is wrong because completing an incident report is not an appropriate action in this situation.
Choice D is wrong because it is the provider’s responsibility to ensure that the client fully understands the procedure and gives informed consent.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.