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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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Free Nursing Study Resources

Correct Answer is B

Explanation

The most concerning finding in the assessment of a client's right leg after a femoropopliteal bypass graft would be if the client's pedal pulse in the right foot is not palpable. This could indicate a problem with blood ﬂow to the limb.

The other options are also concerning and should be reported to the healthcare provider.

a) A cooler footmay indicate decreased blood ﬂow to the limb.

c) A capillary refill time of 5 secondsmay also indicate decreased blood ﬂow.

d) A pain level of 8 on a scale from 0 to 10should also be reported and addressed.

A. A client who has a new onset of chest pain B. A client who has a tracheostomy C. A client who is receiving enteral feedings D. A client who has urinary retention

Correct Answer is A

Explanation

The nurse should identify that caring for a client who has a new onset of chest pain is outside the scope of practice for an LPN. This is a complex and potentially life-threatening situation that requires the assessment and intervention of a registered nurse (RN) or other advanced practice provider.

b) Caring for a client who has a tracheostomy is within the scope of practice for an LPN.

c) Caring for a client who is receiving enteral feedings is within the scope of practice for an LPN.

d) Caring for a client who has urinary retention is within the scope of practice for an LPN.

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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 establishing a baseline postoperative assessment for a client who is recovering from a right femoropopliteal bypass graft. Which of the following findings in the assessment of the client's right leg should be of the most concern to the nurse?

Correct Answer is B

Explanation

A nurse is reviewing client care assignments prior to the beginning of a shift. Which of the following client assignments should the nurse identify as being outside the scope of practice for an LPN?

Correct Answer is A

Explanation

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