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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?

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.

Answer and Explanation

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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Correct Answer is B

Explanation

Answer: B. Elevated skin patches

Rationale:

A. Constipation:
Constipation is not a typical adverse effect of cefazolin. Antibiotics generally cause gastrointestinal symptoms like diarrhea rather than constipation, so this is not a primary concern with cefazolin therapy.

B. Elevated skin patches:
Elevated skin patches may indicate an allergic reaction, such as hives or a rash, which can be a serious side effect of cefazolin. Allergic reactions to antibiotics can escalate quickly and may require immediate medical attention. Monitoring for and reporting any skin changes is important to prevent potential complications.

C. Ringing in the ears:
Tinnitus (ringing in the ears) is not commonly associated with cefazolin. This symptom is more frequently associated with certain other antibiotics, such as aminoglycosides, but is not a primary concern with cefazolin use.

D. Depression:
Depression is not a known side effect of cefazolin. While mood changes may be seen with some medications, cefazolin’s primary side effects are related to hypersensitivity reactions and gastrointestinal symptoms.

A. Elevates the client's legs before applying the stockings B. Instructs the client to dorsiﬂex their feet while applying the stockings C. Massages the client's legs before applying the stockings D. Folds the top of the stockings over after applying them

Correct Answer is A

Explanation

The action by the AP that indicates an understanding of the procedure is elevating the client's legs before applying the stockings. Elevating the legs can help reduce swelling and make it easier to apply the stockings.

Option b is incorrect because instructing the client to dorsiﬂex their feet while applying the stockings may not be necessary.

Option c is incorrect because massaging the client's legs before applying the stockings may not be necessary or appropriate.

Option d is incorrect because folding the top of the stockings over after applying them may not be necessary or appropriate.

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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?

Nursing Test Bank

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Correct Answer is A

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