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 D
Explanation
The nurse should recommend that the client who has diminished breath sounds and paradoxical chest movement receive care first. This client is likely experiencing a tension pneumothorax, which is a life-threatening condition that requires immediate intervention.
Option a is incorrect because a client who has a head injury and whose pupils are fixed and dilated may have experienced brain death and may not be able to be resuscitated.
Option b is incorrect because a dislocated shoulder, while painful, is not immediately life-threatening. Option c is incorrect because a scalp laceration with intermittent bleeding can be managed with pressure and is not immediately life-threatening.
Correct Answer is B
Explanation
The correct answer is b. "I will apply petroleum jelly to the penis with each diaper change."
Choice A rationale:
- It is incorrect to focus on removing all yellow exudate.A small amount of yellow exudate is normal during the healing process after circumcision.Attempting to aggressively clean it off can irritate the delicate healing tissues and cause discomfort for the baby.
- Instead,parents should gently cleanse the area with warm water during diaper changes,allowing any mild exudate to naturally drain.
Choice B rationale:
- Applying petroleum jelly with each diaper change is an essential step in promoting healing and preventing discomfort after circumcision.Here's why:
- Protects against moisture:Petroleum jelly forms a barrier that protects the delicate healing tissues from moisture from urine and feces.This helps to prevent irritation and keeps the area clean.
- Reduces friction:The lubricating properties of petroleum jelly reduce friction between the penis and the diaper,which can minimize discomfort and pain for the baby.
- Promotes healing:Petroleum jelly creates a moist environment that promotes healing and reduces scab formation.This helps the circumcision site to heal faster and more comfortably.
Choice C rationale:
- While ensuring a proper diaper fit is important for overall hygiene,it's not the most crucial aspect of post-circumcision care.A snug diaper can put unnecessary pressure on the healing penis,potentially causing irritation and discomfort.It's generally recommended to choose a diaper that fits comfortably without being too tight.
Choice D rationale:
- Using soap to wash the penis is not recommended during the healing process.Soap can be harsh and drying to the delicate tissues,potentially causing irritation and delaying healing.
- Warm water is sufficient for cleansing the area during diaper changes.
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