A nurse is caring for a large group of patients. She checks on her post-op patient and starts the IV fluids. While programing the pump the nurse is interrupted by another staff member. Three two hours later the nurse rounds and finds that the patient is short of breath, requiring more oxygen and has crackles in her lungs.
The nurse then realizes that the IV fluids were running at twice the ordered rate. What should the nurse do next?
Assess the client
Notify the nurse manager
Complete an incident report
Call the client’s provider
The Correct Answer is A
A. Assess the client.
This is the immediate priority. The nurse should assess the patient's current condition to determine the extent of the impact of the error on the patient's health, focusing on respiratory status, vital signs, and signs of fluid overload.
B. Notify the nurse manager.
Once the patient has been assessed and stabilized, the nurse should inform the nurse manager or supervisor about the error. This helps ensure appropriate reporting, investigation, and follow-up actions.
C. Complete an incident report.
After assessing and stabilizing the patient, the nurse should document the error in an incident report. Incident reports are important for organizational learning, identifying patterns, and implementing improvements to prevent future errors.
D. Call the client’s provider.
If the patient's condition is deteriorating or requires immediate attention, the nurse should contact the healthcare provider to discuss the situation, report the error, and collaborate on necessary interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Dorsal surface of the foot:
The skin on the dorsal surface of the foot may have more pigmentation, making it potentially more challenging to detect cyanosis in individuals with dark skin.
B. Pinnae of the ears:
The ears may have variable pigmentation, and the presence of hair can affect the visibility of cyanosis. The skin on the pinnae may not be as thin as the skin on the dorsal surface of the hand.
C. Dorsal surface of the hand
When assessing for cyanosis in a client with dark skin, the nurse should examine areas with less pigmentation or areas where the skin is thin. The dorsal surface of the hand is often a suitable site, as it is less pigmented and can show bluish discoloration if cyanosis is present.
D. Conjunctivae:
The conjunctivae (the mucous membranes lining the inner surface of the eyelids and covering the white part of the eyes) are not a reliable site for assessing cyanosis in individuals with dark skin. Mucous membranes may not show cyanosis as prominently as the skin.
Correct Answer is B
Explanation
A. Place the client on bed rest in supine position:
While bed rest might be appropriate for certain respiratory conditions, it is not a specific intervention for crackles. In fact, changing the client's position, such as having them sit up, may enhance lung function and help with breathing.
B. Repeat auscultation after asking the client to breathe deeply and cough:
This is the correct action. Repeating auscultation after having the client take deep breaths and cough can provide additional information about the nature of the crackles and may help clear the airways temporarily.
C. Prepare to administer antibiotics:
Administering antibiotics would be considered if the crackles are indicative of a respiratory infection. However, determining the need for antibiotics would require a more comprehensive assessment, including diagnostic tests.
D. Instruct the client to limit fluid intake to less than 2,000 mL/day:
Limiting fluid intake is not a direct intervention for crackles. This action is typically considered in conditions like heart failure where there is a risk of fluid overload. It is not the primary intervention for addressing crackles in the lungs.
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