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 ["A","D","G","H"]
Explanation
A. Obtain a serum WBC count: A WBC count will help assess for infection, as the client presents with fever, confusion, and urinary symptoms. Elevated WBC could suggest a urinary tract infection (UTI) or other infection.
B. Insert indwelling urinary catheter: An indwelling catheter is not immediately necessary unless the client is unable to void or requires continuous monitoring. Non-invasive methods like obtaining a urine sample for analysis would be a priority.
C. Make the client NPO: There is no indication that the client requires NPO status at this time. Unless surgery or another procedure is planned, this is not necessary.
D. Initiate antibiotic therapy: Given the client's symptoms (fever, confusion, urinary frequency, urgency, and dark urine), a UTI or other infection is likely. Antibiotics are needed to treat the suspected infection.
E. Obtain a consent for surgery: There is no indication that surgery is needed based on the current clinical information. The primary concern is infection, not surgical intervention.
F. Withhold metoprolol: While metoprolol may lower blood pressure, there is no indication to withhold it at this time. The client’s blood pressure is already low, and withholding this medication could worsen hypotension. Any changes in the medication regimen should be made based on further evaluation by the provider.
G. Administer acetaminophen: Acetaminophen is indicated to help reduce the client's fever (39.3°C/102.7°F). Managing the fever will help improve comfort and prevent complications like delirium.
H. Collect urine for urinalysis and culture and sensitivity: Urine analysis and culture will help confirm the presence of a UTI, identify the causative pathogen, and guide appropriate antibiotic therapy.
I. Obtain chest x-ray: A chest x-ray is not necessary unless there is a suspicion of a respiratory infection, such as pneumonia. The symptoms are more consistent with a UTI or systemic infection, so a chest x-ray is not a priority.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Daily weights: This task can be delegated to ensure consistent monitoring of the client's weight, which is crucial for assessing nutritional status and progress.
Observing meals: The nurse should focus on observing meals to ensure the client is eating properly and not engaging in behaviors such as pocketing food or spitting it out, which are common in clients with eating disorders.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.