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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Placing a cap holder on the used needle before disposal does not prevent needlestick injuries and may increase the risk of accidental puncture.
B. Recapping the needle for disposal later increases the risk of needlestick injuries. It is recommended to avoid recapping needles whenever possible.
C. The immediate disposal of the used needle in a sharps container reduces the risk of needlestick injuries by eliminating the need for handling the needle after use.
D. Detaching the used needle and disposing of it promptly is appropriate, but it should be done directly into a sharps container to minimize the risk of needlestick injuries.
Correct Answer is C
Explanation
A. Incorrect. This response dismisses the client's concerns and does not acknowledge the distress the client may be experiencing.
B. Incorrect. While it's true that paranoia is a common symptom of schizophrenia, stating that it is "normal" may invalidate the client's feelings and does not address the underlying distress. C. Correct. This response validates the client's feelings and demonstrates empathy by acknowledging the distress associated with the belief that government agents are after them.
D. Incorrect. While medication management is important in the treatment of schizophrenia, this response does not address the client's immediate concerns or validate their feelings of persecution.
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