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
As individuals age, there is a natural decline in kidney function. This can result in a reduced ability to filter and excrete medications and their metabolites from the body. The decreased kidney function can lead to a longer half-life of medications, increased drug accumulation, and an increased risk of adverse drug reactions. It is important for the nurse to adjust medication dosages and frequencies based on the individual's renal function to prevent drug toxicity.
Increased liver function: Aging is associated with a gradual decline in liver function. While there may be some individual variations, in general, liver function decreases rather than increases with age. However, changes in liver function can affect the metabolism and elimination of medications. Some medications may require dosage adjustments based on liver function, but it is not a common physiological change in older adults.
Increased metabolism: Aging is generally associated with a decrease in metabolism rather than an increase. The metabolic rate tends to slow down with age, which can affect the pharmacokinetics of medications. Slower metabolism can result in medications taking longer to be metabolized and cleared from the body, potentially leading to prolonged drug effects.
Decreased pulmonary function: While it is true that lung function decreases with age, the impact on medication administration is not as significant compared to kidney function. Medications are usually administered through non-pulmonary routes (e.g., oral, intravenous, transdermal), and decreased pulmonary function primarily affects the absorption of inhaled medications. However, certain respiratory conditions or compromised lung function may influence medication choices or require adjusted dosing.
Correct Answer is D
Explanation
Placenta previa is a condition where the placenta partially or completely covers the opening of the cervix. One of the hallmark signs of placenta previa is painless vaginal bleeding, typically bright red in color. This bleeding can occur spontaneously or during activities that put pressure on the uterus, such as sexual intercourse or physical exertion.
A rigid abdomen is not typically associated with placenta previa. It may indicate other conditions, such as peritonitis or abdominal muscle rigidity, but it is not a characteristic finding of placenta previa.
Persistent uterine contractions are not typically associated with placenta previa. Placenta previa is more commonly associated with painless bleeding rather than contractions. However, if placenta previa is complicated by other factors, such as placental abruption, contractions and abdominal pain may be present.
Fetal movement is not directly related to placenta previa. Fetal movement can vary from person to person and does not specifically indicate placenta previa. However, it is important for the nurse to assess fetal well-being in clients with placenta previa as bleeding can impact the oxygen supply to the fetus.
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