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 ["A","C","D","F"]

Explanation

A. Blood pressure. A blood pressure of 162/112 mm Hg is severely elevated and indicative of preeclampsia, a serious complication during pregnancy. Uncontrolled hypertension can lead to maternal and fetal complications, such as eclampsia, placental abruption, or fetal growth restriction.

B. Urine ketones. The absence of ketones in the urine is normal and does not indicate any prenatal complication. Ketones would typically be seen in cases of starvation, dehydration, or poorly controlled diabetes, which are not evident here.

C. Urine protein. The presence of 3+ protein in the urine is a key diagnostic marker for preeclampsia. This finding, combined with elevated blood pressure, signals potential damage to the kidneys, which is a hallmark of severe preeclampsia.

D. Report of headache. A severe headache unrelieved by acetaminophen is a concerning symptom of preeclampsia. It suggests potential central nervous system involvement, which could lead to complications like seizures if left untreated.

E. Respiratory rate. The client’s respiratory rate of 16/min is within the normal range and does not indicate any immediate concern related to her pregnancy or current condition.

F. Fetal activity. The client’s report of decreased fetal movement is concerning and may indicate fetal distress or compromised placental function. This finding requires prompt evaluation to ensure fetal well-being.

Correct Answer is []

Explanation

Potential Condition: Kawasaki Disease

Kawasaki disease is a systemic vasculitis that primarily affects children under the age of 5 but can occur in older children. It presents with prolonged fever (lasting more than 5 days), conjunctival injection (red eyes without exudate), mucosal inflammation (strawberry tongue, red lips), maculopapular rash, and extremity changes (edema and peeling skin on hands and feet). Elevated inflammatory markers (C-reactive protein and erythrocyte sedimentation rate), high WBC count, and thrombocytosis (elevated platelets) are consistent with Kawasaki disease. If untreated, it can lead to coronary artery aneurysms.

Actions to Take:

Plan to administer high dose of aspirin:

High-dose aspirin is given to reduce inflammation and prevent thrombosis in coronary arteries, as Kawasaki disease increases the risk of coronary artery aneurysms.

Assess for neurological changes:

Neurological changes, such as irritability, can indicate aseptic meningitis or other central nervous system involvement, which can occur in Kawasaki disease.

Parameters to Monitor:

Daily weights:

Monitoring daily weights is essential to assess for fluid retention or overload, as Kawasaki disease can cause myocarditis and cardiac dysfunction.

Reports of chest pain or pressure:

Monitoring for chest pain or pressure is crucial to detect early signs of myocardial ischemia or coronary artery involvement, which are potential complications of Kawasaki disease.

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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?

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Correct Answer is ["A","C","D","F"]

Explanation

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Explanation

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