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 C
Explanation
Answer: C
Rationale:
A) Apply a topical corticosteroid ointment to the scalp: Corticosteroids are not indicated for the treatment of Pediculosis capitis (head lice). The treatment focuses on eliminating the lice and nits, typically through pediculicide medications like permethrin or ivermectin. Corticosteroids are used to reduce inflammation and itching, but they do not kill the lice or their eggs.
B) Soak hair brushes and combs in soapy water: Soaking hair brushes and combs in soapy water alone is not sufficient to kill lice. Items such as hair brushes should be soaked in hot water (130°F or higher) for at least 5-10 minutes to ensure any lice or nits present are killed. This is a critical step to prevent reinfestation.
C) Wash the bed linens in hot water: Washing bed linens in hot water (130°F or higher) is essential to eliminate lice and nits that may have transferred onto bedding. This prevents the spread and recurrence of lice. Items that cannot be washed should be sealed in a plastic bag for 2 weeks to kill the lice.
D) Clean the child's toys with a 1:10 bleach solution: Lice are spread through direct contact and cannot live on inanimate objects for long periods. Cleaning toys with bleach is unnecessary for lice removal and can be harmful to the toys or the child if not properly rinsed.
Correct Answer is C
Explanation
c. Dispose of the used needle immediately in a sharps container.
The nurse should dispose of the used needle immediately in a sharps container to reduce the risk of a needlestick injury. Sharps containers are specifically designed for the safe disposal of needles and other sharp objects. By placing the used needle directly into a sharps container, the nurse eliminates the need for handling or manipulating the needle further, reducing the risk of accidental needlestick injuries.
Explanation for the other options:
a. Place a cap holder securely on the used needle before disposal: Cap holders are not recommended for securing used needles before disposal. They may not provide adequate protection against needlestick injuries and can potentially increase the risk of accidental needlesticks when atempting to secure the cap holder.
b. Recap the needle for disposal later: Recapping the needle increases the risk of a needlestick injury. It is generally not recommended to recap needles after use, as it poses a greater risk of accidental puncture.
d. Detach the used needle and dispose of it promptly: Detaching the needle from the syringe before disposal is not recommended, as it increases the risk of a needlestick injury. It is safer to dispose of the needle and syringe as a unit in a sharps container to minimize the risk of accidental puncture.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today