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

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A. Develop a plan of care for the client:

Developing a plan of care is essential, but it should be informed by the client's current condition, diagnosis, and code status. Documenting the code status is a foundational step.

B. Provide a schedule of visiting hours to the client’s family:

While facilitating family involvement is important, it is not the top priority during the initial admission assessment. Ensuring the client's safety and understanding their code status takes precedence.

C. Teach the client about his diagnosis:

Patient education is important, but in a critical situation, the priority is to assess and document key information, including the code status. Education can follow once the immediate priorities are addressed.

D. Document the client’s code status

When conducting the initial admission assessment for a critical client, the priority action is to document the client's code status. Code status refers to the set of directives given by the client or their legal representative regarding the use of cardiopulmonary resuscitation (CPR) and other life-sustaining measures in the event of a cardiac or respiratory arrest.

Understanding and documenting the client's code status is crucial for informing the healthcare team about the client's preferences for resuscitation efforts. This information guides the team in providing care that aligns with the client's wishes and values.

A. An incident report was completed B. There were no injuries sustained C. The provider was notified D. An incident report was forwarded to risk management

Correct Answer is C

Explanation

Correct Answer: C

C. The provider was notified.The nurse should document objective facts, such as notifying the provider, in the client’s medical record. This ensures accurate communication about the client's condition and the steps taken after the fall.

Incorrect answers:

A."An incident report was completed."The completion of an incident report should not be documented in the medical record. Incident reports are internal documents used for quality improvement and risk management, and mentioning them in the medical record could make them discoverable in legal proceedings.

B."There were no injuries sustained."While documenting the client’s physical condition is appropriate, stating "no injuries sustained" might be premature or subjective. Instead, the nurse should record specific observations, such as "client denies pain" or "no visible signs of injury noted."

D."An incident report was forwarded to risk management.Referencing the incident report in the medical record is inappropriate. Incident reports are separate from the client’s medical record and should not be mentioned in the documentation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing the initial admission assessment and history for a critical client. Which of the following is the priority action for the nurse to take?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

A nurse performs an integumentary assessment of a client who has recently fallen and broken his leg. The nurse notes the skin coloring on the broken leg is bluish gray. What is the term for this change in skin color?

A nurse is orienting a newly licensed nurse about documentation of a client’s information in the electronic health record. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation?

Order: Ampicillin (Principen) 150 mg PO every 6 hours Available: Ampicillin (Principen) 125mg per 5 ml How many mL of ampicillin are needed for one dose? ( Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero. TYPE THE ANSWER ONLY, no label )

Ordered: Hydroxyzine (Vistaril) 35 mg IM stat Available: Hydroxyzine (Vistaril) 50 mg/mL Administer: ____ ml

A nurse is assessing a client’s circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?

A nurse is assessing a client’s radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?

A nurse is completing a client’s history and physical examination. Which of the following information should the nurse consider subjective data?

A nurse is preparing to collect health history data during a client’s admission. Which of the following questions should the nurse use to promote this discussion?