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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Correct Answer is B

Explanation

A. Redo the initial assessment and document current findings:

This option suggests repeating the entire initial assessment. While reassessment is important, redoing the entire initial assessment may not be necessary. Instead, a focused assessment on the specific area of concern (skin integrity) is more appropriate.

B. Perform and document a focused assessment of skin integrity:

This is the recommended choice. If unexpected findings are observed during care, such as reddened areas over bony prominences, it is important to conduct a focused assessment on the skin to identify any issues and document the findings accurately.

C. Correct the initial assessment form:

Simply correcting the initial assessment form may not address the immediate need for assessing and addressing the reddened areas. It is more crucial to perform a focused assessment on the skin.

D. Conduct and document an emergency assessment:

Reddened areas over bony prominences may not necessarily indicate an emergency. However, addressing the issue promptly is important. A focused assessment would be more appropriate than conducting a full emergency assessment.

A. Dorsal surface of the foot B. Pinnae of the ears C. Dorsal surface of the hand D. Conjunctivae

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.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When you receive the shift report, you learn that your patient has no special skin care needs. You are surprised during the bath to observe reddened areas over bony prominences. What action is appropriate?

Correct Answer is B

Explanation

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

Correct Answer is C

Explanation

A nurse is assisting with the admission of an alert and oriented client to the orthopedic surgical unit. Which of the following sources of information should the nurse rely on for accurate information about the client?

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 taking a blood pressure measurement to assess for orthostatic hypotension in a client. Which signs and symptoms will the nurse assess related to this condition? (Select all that apply.)

The nurse is surprised to detect an elevated temperature (102 °F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the first thing the nurse should do?

By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process?

A nurse is measuring a client’s oral temperature. The thermometer reads 33 C (91.4F). Which of the following actions should the nurse take? (Select all that apply)

A patient is having dyspnea. What would the nurse do first?

While taking an adult patient’s pulse, a nurse finds the rate to be 140 beats/min. What should the nurse do next?