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 A
- 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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is E,D,C,B,A
Explanation
E: The first step is to turn off the IV infusion pump and clamp the IV tubing to prevent air from entering the line and to stop the flow of medication or fluids.
D: Next, allowing the preschooler to assist with removing the transparent dressing can help in reducing anxiety and providing a sense of control, which is important for a child's emotional well-being during medical procedures.
B: Applying firm pressure at the IV site after the catheter is removed helps to prevent bleeding and ensures the closure of the venipuncture site.
C: Removing the IV catheter while keeping the catheter hub parallel to the insertion site minimizes discomfort and the risk of damaging the vein.
A: Finally, inspecting the IV catheter tip after removal is essential to ensure that the entire catheter has been removed and that no part has been left in the vein.
Correct Answer is C
Explanation
Choice A Rationale: Puncturing the heel to a depth of 4 mm may be too deep and could cause injury to the newborn's foot. The recommended depth is usually less than 2 mm to avoid damaging underlying bone or tissues.
Choice B Rationale: Withholding feeding prior to collecting the specimen is not necessary and could cause unnecessary distress to the newborn. Feeding can help in soothing the infant and may even improve blood flow for the procedure.
Choice C Rationale: Applying a heat pack 5 to 10 minutes prior to the procedure is recommended as it helps to increase blood flow to the area, making the collection easier and potentially less painful for the newborn.
Choice D Rationale: Elevating the newborn's foot for 15 minutes following the procedure is not a standard recommendation. Post-procedure care typically involves applying gentle pressure to stop bleeding and then covering the puncture site with a bandage.
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