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

Answer and Explanation

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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Correct Answer is C

Explanation

A. Vitamin C: While a vegan diet may limit sources of vitamin C, it is typically abundant in fruits and vegetables, so deficiency is less likely.
B. Potassium: Potassium deficiency is not typically associated with a vegan diet, as plant-based foods such as fruits, vegetables, legumes, and nuts are good sources of potassium.
C. Vitamin D: Vitamin D is primarily found in animal products, so individuals following a vegan diet may be at risk of deficiency unless they consume fortified foods or supplements.
D. Magnesium: While magnesium deficiency can occur in anyone with an inadequate intake of magnesium-rich foods, it's not necessarily more common in vegans compared to omnivores.

A. Serum calcium 12.5 mg/dL B. BUN 16 mg/dL C. Serum potassium 4.6 mEq/L D. WBC count 8,000/mm3

Correct Answer is A

Explanation

A. An elevated serum calcium level (hypercalcemia) can indicate a complication of total parenteral nutrition, such as hypercalcemia resulting from excess calcium supplementation in the
TPN solution, which can lead to complications such as renal calculi and cardiac dysrhythmias.
B. The blood urea nitrogen (BUN) level within the normal range does not indicate a complication related to total parenteral nutrition.
C. The serum potassium level within the normal range does not indicate a complication related to total parenteral nutrition.
D. A normal white blood cell (WBC) count does not indicate a complication related to total parenteral nutrition.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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