A nurse is conducting an initial assessment of a client and notices a discrepancy between the client's current IV infusion and the report received during the shift report. Which of the following actions should the nurse take?
Complete an incident report and place it in the client's medical record.
Compare the current infusion with the prescription in the client's medication record.
Contact the charge nurse to see if the prescription was changed.
Submit a written warning for the nurse involved in the incident.
The Correct Answer is B
A. An incident report is appropriate but should not be placed in the client’s medical record.
B. The nurse should first compare the current infusion with the prescription in the client's medication record to ensure the client is receiving the correct medication and dosage.
C. The nurse should verify the prescription before contacting the charge nurse.
D. Submitting a written warning is not the nurse's responsibility and is not appropriate in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Sinus tachycardia: Incorrect. Sinus tachycardia shows a regular rhythm with identifiable P waves, not a wavy baseline.
B. Atrial fibrillation: The wavy baseline and absent P waves are characteristic of atrial fibrillation, a common arrhythmia that results from rapid and irregular electrical activity in the atria.
C. Second-degree heart block: Incorrect. Second-degree heart block would show P waves with intermittent conduction of the QRS complex, not a wavy baseline.
D. Ventricular asystole: Incorrect. Ventricular asystole would show no electrical activity, which is different from a wavy baseline.
Correct Answer is D
Explanation
A. Monitoring every 30 minutes is insufficient; it should be more frequent.
B. Providers must evaluate the client within 1 hour of restraint initiation, not 36 hours.
C. Restraint prescriptions for adults must be renewed every 4 hours, not 6.
D. Documenting the client’s behavior every 15 minutes ensures continuous assessment and compliance with safety protocols.
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