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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 D

Explanation

A client with heart failure should limit their sodium intake. Bottled salad dressings can be high in sodium, so replacing them with homemade vinegar and oil dressing can help reduce sodium intake.

The other options are not recommended for a client with heart failure who needs to limit their sodium intake.

a) Prepared frozen dinners are often high in sodium.

b) Adding salt when preparing a meal would increase sodium intake.

c) Imitation crab and lobster products (option can also be high in sodium.

A. "I should keep my baby rear-facing in the car seat until she is 2 years old." B. "I should place my baby in the car seat at a 90-degree angle." C. "I should position the car seat's retainer clip at the level of my baby's belly button." D. "I should enable the airbag when my baby is in the front seat of the car."

Correct Answer is A

Explanation

Keeping a baby rear-facing in the car seat until they reach the age of 2 years old or until they reach the maximum height and weight limits recommended by the car seat manufacturer is a crucial safety guideline. Rear-facing car seats provide better support for a baby's head, neck, and spine in the event of a crash, reducing the risk of severe injuries.

"I should place my baby in the car seat at a 90-degree angle." The correct positioning for a rear-facing car seat is typically between a 30 to 45-degree angle. This angle helps ensure the baby's airway remains open and prevents their head from flopping forward.

"I should position the car seat's retainer clip at the level of my baby's belly button." The retainer clip of the car seat should be positioned at armpit level, not at the level of the baby's belly button. The retainer clip is designed to secure the harness straps and should be placed across the chest, resting on the bony part of the shoulders.

"I should enable the airbag when my baby is in the front seat of the car." It is not safe to have a rear-facing car seat with a baby in the front seat of a vehicle with an active airbag. Airbags can pose a significant risk to infants due to the force with which they deploy. It is recommended to place a rear-facing car seat in the back seat of the vehicle and disable the airbag in the front passenger seat if the baby needs to ride in the front.

It is important for parents to receive proper education on car seat safety and follow the guidelines set forth by car seat manufacturers, national recommendations, and local laws and regulations.

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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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has heart failure and reports difficulty with limiting sodium in their diet. Which of the following recommendations should the nurse provide?

Correct Answer is D

Explanation

A nurse is reinforcing teaching about car seat safety with a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?

Correct Answer is A

Explanation

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