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. Identifying a sour taste tests cranial nerves VII (facial) and IX (glossopharyngeal).
B. Cranial nerve XI (the spinal accessory nerve) controls the muscles involved in shoulder shrugging and head turning.
C. Frowning symmetrically assesses the facial nerve (VII).
D. Sticking out the tongue assesses the hypoglossal nerve (XII).
Correct Answer is C
Explanation
A. A cool mist tent may be helpful for other respiratory conditions but is not the priority in epiglottitis.
B. Suctioning the oropharynx can cause further airway irritation and increase the risk of airway obstruction.
C. Epiglottitis can rapidly lead to airway obstruction, and intubation may be necessary to secure the airway.
D. Obtaining a throat culture is contraindicated as it may trigger airway closure.
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