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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Wearing well-fitted shoes at home helps prevent slips and falls.

B. Placing throw rugs over electrical cords increases the risk of tripping.

C. Area rugs with rubber backs prevent slipping, reducing the risk of falls in a postoperative client.

D. Marking doorways with tape is not necessary for a client after knee replacement and may be more applicable for clients with visual impairments.

A. Wear sterile gloves to collect the specimen from the client. B. Obtain the specimen immediately upon the client waking up. C. Wait 1 day to collect the specimen if the client cannot provide sputum. D. Ask the client to provide 15 to 20 mL of sputum into the container.

Correct Answer is B

Explanation

A. Clean gloves (not sterile) are sufficient for collecting a sputum sample.

B. The best time to collect a sputum specimen is immediately upon waking because secretions accumulate overnight, making it easier to obtain a sample.

C. Waiting a day delays diagnosis and treatment; other techniques can help induce sputum production.

D. Typically, 5 to 10 mL of sputum is sufficient for diagnostic testing.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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