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 C
Explanation
Answer: C
Rationale:
A) Encourage strength-training exercise: Strength-training exercises can be beneficial in building muscle mass and improving overall strength. However, for a client with leukemia experiencing chronic fatigue, this may be too strenuous and could exacerbate their fatigue rather than alleviate it. It is better to encourage light to moderate activities based on their tolerance.
B) Increase the client's fluids to 4 L per day: While adequate hydration is important, increasing fluids to 4 L per day may not be suitable for all clients and could pose risks, particularly if there are concerns about fluid balance or renal function. This recommendation should be tailored to the client's specific needs and medical condition.
C) Increase protein in the diet: Increasing protein in the diet can help improve energy levels and support the body's repair and regeneration processes. For clients with leukemia who are experiencing chronic fatigue, a high-protein diet can aid in maintaining muscle mass and overall nutritional status, helping to combat fatigue.
D) Encourage the client to have continual bed rest: Encouraging continual bed rest can lead to deconditioning and further exacerbate fatigue. It is important to balance rest with periods of gentle activity to maintain some level of physical function and avoid complications such as muscle atrophy or deep vein thrombosis.
Correct Answer is D
Explanation
The first action the nurse should take is to reevaluate the client's response to the medication in 30 min. Hydromorphone has an onset of action of 15 to 30 minutes when taken orally ¹. Therefore, it may take some time for the medication to reach its full effect.
Option a is incorrect because it may not be necessary to contact the provider for more pain medication until after reevaluating the client's response to the medication.
Option b is incorrect because teaching relaxation techniques may not provide immediate relief for acute pain.
Option c is incorrect because documenting the client's reaction to the administration of medication should be done after reevaluating their response to the medication.
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