A nurse is caring for a client who is receiving IV fluids. The nurse realizes that the incorrect
IV solution is infusing. Which of the following actions should the nurse take?
Complete an incident report.
Allow the current solution to finish infusing, then change the bag.
Document that an error occurred in the client's medical record
Stop the infusion
The Correct Answer is D
- A: Completing an incident report is an important step after addressing any immediate risks to the patient. It is a part of the process to document errors and prevent future occurrences, but it does not take precedence over the patient's immediate safety.
- B: Allowing the current solution to finish could harm the patient, depending on the contents of the IV solution and the patient's condition. Immediate action is required to prevent potential adverse effects.
- C: Documentation in the medical record is crucial, but it should be done after the error has been corrected and the patient's safety is ensured. The immediate priority is to address the error.
- D: Stopping the infusion is the most immediate and appropriate action to prevent further harm to the patient. Once the infusion is stopped, the nurse can then take further steps to correct the error and follow up with the necessary documentation and reports.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Instruct the client to report the theft to the police: While reporting theft to the police may be necessary, the immediate concern is the safety and well-being of the client, especially if financial exploitation or abuse is suspected.
B. Report the possible abuse to adult protective services: Suspected financial exploitation or abuse of an older adult should be reported to the appropriate authorities, such as adult protective services, for investigation and intervention.
C. Ask the client if there is another family member they can call for financial help: While involving other family members may be appropriate in some situations, suspected abuse or exploitation requires intervention from trained professionals.
D. Restrict visitation for the client's family until discharge: Restricting visitation should only be done if there is a clear risk to the client's safety, and it should not be the first action taken in response to suspected abuse.
Correct Answer is D
Explanation
A. Heart rate elevation could indicate pain, but it's an objective sign rather than subjective. Pain should be assessed based on the client's self-report.
B. Guarding the abdominal incision is an objective sign of pain and discomfort but does not reflect the client's perception of pain.
C. Facial grimacing is an objective sign of pain but may not always correlate with the client's perception of pain.
D. The client's report of pain is a subjective indication that they are experiencing discomfort and need PRN pain medication. It is essential to address the client's self-reported pain to provide adequate relief and promote comfort and recovery.
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