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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Free Nursing Study Resources

Correct Answer is D

Explanation

A. He has an electrical burn, which caused coagulation of some tissues:

This response provides more detailed information about the nature of the electrical burn, mentioning tissue coagulation. However, it may be more information than the family needs at this point, and it's important to balance providing information with respecting the client's privacy.

B. He is doing well, although he might be in the hospital for some time:

While this response aims to reassure the family about the client's general status, it might not be entirely accurate or provide specific information about the client's condition. It's important to be transparent while respecting the client's privacy.

C. He does not appear to have much damage and should be fine soon:

This response may provide a sense of reassurance to the family, but it might oversimplify the situation. It's important to provide accurate and honest information while respecting the client's privacy.

D. He has an electrical burn. He is stable, and we will update you with any changes:

This response acknowledges the type of injury, assures the family that the client is stable, and communicates a commitment to keeping the family informed of any changes. It strikes a balance between providing some information and maintaining the client's privacy and confidentiality.

A. Pallor B. Jaundice C. Cyanosis D. Erythema

Correct Answer is C

Explanation

A. Pallor:

Pallor refers to an unusually pale or white skin color. It is often associated with reduced blood flow, anemia, or shock. Pallor is characterized by a lack of the normal rosy color of the skin.

B. Jaundice:

Jaundice is a yellowing of the skin and mucous membranes due to an excess of bilirubin in the blood. It can be associated with liver dysfunction or other conditions affecting the normal breakdown and elimination of bilirubin.

C. Cyanosis:

Cyanosis is a bluish-gray discoloration of the skin and mucous membranes caused by a decrease in oxygen levels in the blood. It can result from various conditions affecting oxygenation, such as respiratory or circulatory problems. In the context of a broken leg, cyanosis on the affected leg could suggest compromised blood flow or oxygenation.

D. Erythema:

Erythema refers to redness of the skin, often due to increased blood flow to the area. It can be a normal response to irritation, injury, or inflammation. Unlike bluish-gray discoloration seen in cyanosis, erythema is characterized by a red appearance.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an electrical burn. With the client’s permission, the nurse is answering questions from the family about his status. Which of the following responses should the nurse make?

Correct Answer is D

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?

Correct Answer is C

Explanation

A client has just been admitted to the postanesthesia care unit (PACU) after having a procedure to bypass arteries in the right leg. Which assessment should receive the highest priority?

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 )

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?

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?

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment, what finding would the nurse expect?

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

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?