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.
Remove the IV catheter.
The Correct Answer is D
d. Remove the IV catheter.
Explanation:
The correct answer is d. Remove the IV catheter.
If the nurse realizes that the incorrect IV solution is infusing, it is essential to take prompt action to prevent harm to the client. Removing the IV catheter is the appropriate course of action to stop the infusion of the incorrect solution.
Option a, completing an incident report, may be necessary after the immediate situation has been addressed, but it should not be the nurse's first action. The priority is to stop the incorrect solution from infusing.
Option b, allowing the current solution to finish infusing and then changing the bag, is not the correct action. Continuing the infusion of the incorrect solution can potentially harm the client and must be stopped immediately.
Option c, documenting that an error occurred in the client's medical record, is important, but it should be done after taking immediate action to stop the incorrect solution from infusing. Documentation should include the details of the incident, any actions taken, and the client's response.
By promptly removing the IV catheter, the nurse stops the infusion of the incorrect solution and prevents further harm to the client. Afterward, the nurse should assess the client for any adverse effects, inform the appropriate healthcare providers, and follow the facility's policies and procedures for reporting incidents and documenting the error.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
b. A decreased level of consciousness and vomiting
Explanation:
When receiving report on four clients, the nurse should first collect data about the client who has a decreased level of consciousness and vomiting. This combination of symptoms suggests a potentially serious condition that requires immediate atention and assessment. It could indicate a neurological or gastrointestinal issue, and further evaluation is necessary to determine the underlying cause and provide appropriate interventions.
Explanation for the other options:
a. Cellulitis accompanied by a low-grade fever:
While cellulitis and a low-grade fever require atention, they are not as immediately critical as a decreased level of consciousness and vomiting. The nurse should prioritize assessing the client with altered consciousness and vomiting due to the potential for more urgent interventions.
c. A pain rating of 7 on a scale from 0 to 10 after receiving analgesia 30 min ago:
Although the client's pain rating of 7 indicates ongoing pain, it is not as immediately critical as a decreased level of consciousness and vomiting. The nurse should first address the client with altered consciousness to determine the cause and provide appropriate interventions before assessing and managing pain in other clients.
d. Type 2 diabetes mellitus and a blood glucose level of 160 mg/dL:
While elevated blood glucose levels in a client with type 2 diabetes require atention and management, they are not as immediately critical as a decreased level of consciousness and vomiting. The nurse should first assess the client with altered consciousness to identify the cause and provide prompt interventions.
In summary, when receiving report on four clients, the nurse should first collect data about the client who has a decreased level of consciousness and vomiting. These symptoms indicate a potentially serious condition requiring immediate assessment and intervention.
Correct Answer is B
Explanation
Answer: B. You can take a shower 1 day after your procedure.
Rationale:
A. You can resume a regular diet 3 days after your procedure:
There is typically no need to delay resuming a regular diet for three days after a cardiac catheterization. Most clients can resume their usual diet shortly after the procedure once they are fully awake and any nausea has resolved.
B. You can take a shower 1 day after your procedure:
It is generally safe to shower the day after a cardiac catheterization as long as the insertion site remains protected. Clients should avoid soaking in a bath or swimming until the site is fully healed to prevent infection.
C. You can begin exercising 2 days after your procedure:
Strenuous activities, including exercise, should generally be avoided for a few days to a week following a cardiac catheterization. This allows time for the insertion site to heal and reduces the risk of complications such as bleeding.
D. You can return to school 1 week after your procedure:
Most clients can return to school or normal activities within a few days, provided they feel well and avoid excessive physical exertion. A full week off is typically not necessary unless specified by the healthcare provider based on the individual’s recovery.
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