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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The instruction that the nurse should include is "You can take a shower 1 day after your procedure." According to the Cleveland Clinic, the morning after the procedure, the client may take the dressing off the catheter insertion site. The easiest way to do this is when showering, get the tape and dressing wet and remove it.
Option a is incorrect because there is no information suggesting that a client must wait 3 days before resuming a regular diet after a cardiac catheterization.
Option c is incorrect because according to the Cleveland Clinic, clients should gradually increase their activities until they reach their normal activity level within one week after the procedure.
Option d is incorrect because there is no information suggesting that a client must wait 1 week before returning to school after cardiac catheterization.
Correct Answer is D
Explanation
Placenta previa is a condition where the placenta partially or completely covers the opening of the cervix. One of the hallmark signs of placenta previa is painless vaginal bleeding, typically bright red in color. This bleeding can occur spontaneously or during activities that put pressure on the uterus, such as sexual intercourse or physical exertion.
A rigid abdomen is not typically associated with placenta previa. It may indicate other conditions, such as peritonitis or abdominal muscle rigidity, but it is not a characteristic finding of placenta previa.
Persistent uterine contractions are not typically associated with placenta previa. Placenta previa is more commonly associated with painless bleeding rather than contractions. However, if placenta previa is complicated by other factors, such as placental abruption, contractions and abdominal pain may be present.
Fetal movement is not directly related to placenta previa. Fetal movement can vary from person to person and does not specifically indicate placenta previa. However, it is important for the nurse to assess fetal well-being in clients with placenta previa as bleeding can impact the oxygen supply to the fetus.
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