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 D

Explanation

Rationale for A: While contacting a shelter in another county might be a good long-term option, the client should prioritize preparing for an immediate, safe escape rather than focusing on geographic distance.

Rationale for B: Telling the client to leave immediately may not be feasible or safe. The client needs to be prepared with a well-thought-out plan, including knowing when and how to leave, based on the safest opportunity.

Rationale for C: Keeping a packed bag by the front door may alert the abuser and increase the risk of violence. Instead, the bag should be kept in a secure and hidden location to avoid raising suspicion.

Rationale for D: Rehearsing an escape route is a critical component of a safety plan. It ensures the client knows how to leave quickly and safely in case of an emergency, which is vital for their safety.

A. Coordinating client care B. Providing direct client care C. Assessing a client's health status D. Identifying specific client health problems E. Identifying specific client health problems

Correct Answer is B

Explanation

A. Coordinating client care is typically a responsibility of registered nurses (RNs) who have advanced training and education in care coordination and management.
B. Providing direct client care, under the supervision of registered nurses or physicians, is a primary responsibility of licensed practical nurses (LPNs). This may include administering medications, assisting with activities of daily living, and monitoring clients' vital signs.
C. Assessing a client's health status is within the scope of practice of both registered nurses and licensed practical nurses, but LPNs typically perform more focused assessments compared to
RNs.
D. Identifying specific client health problems often involves critical thinking and clinical judgment, which are skills typically developed through higher levels of education and experience. While LPNs may identify issues during routine care, diagnosing health problems is generally the responsibility of the healthcare provider.

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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?

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