A client receiving an IV medication reports dizziness and nausea. What should the LVN do first?
Document findings
Reassure the client this is expected
Administer an antiemetic
Stop the infusion and assess vital signs
The Correct Answer is D
Rationale:
A. Document findings is incorrect because while documentation is essential in nursing practice, it is not the immediate priority when a client is experiencing symptoms that could indicate a serious reaction. Recording information without first addressing the potential problem delays interventions that may prevent harm. Documentation should always follow assessment and stabilization.
B. Reassure the client this is expected is incorrect because telling the client that dizziness and nausea are normal could downplay potentially serious signs. These symptoms could indicate hypotension, an allergic reaction, rapid infusion, or fluid/electrolyte imbalance. Reassurance without assessment puts the patient at risk and may delay emergency intervention if needed.
C. Administer an antiemetic is incorrect because giving medication before assessing the patient could mask important clinical signs. While an antiemetic might relieve nausea, it does not address the underlying cause, which could be hypotension, a medication reaction, or fluid overload. Administering treatment without assessment violates patient safety principles.
D. Stop the infusion and assess vital signs is correct. Stopping the infusion prevents further exposure to the medication that may be causing the reaction, and assessing vital signs helps determine if the patient is experiencing hypotension, tachycardia, or other signs of adverse reaction. After this assessment, the nurse can notify the provider, provide supportive care, and document appropriately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Carefully remove the gloves and follow with hand hygiene is correct because gloves are considered personal protective equipment (PPE) that protect the nurse from exposure to bloodborne pathogens. Once contaminated, gloves should be removed properly to prevent further contamination, followed immediately by hand hygiene to ensure any residual microorganisms on the skin are removed. This follows standard infection control protocols.
B. Prepare an incident report is incorrect because a blood spill on gloves does not require an incident report if no exposure occurred and proper procedures were followed. Incident reports are reserved for needlestick injuries or other breaches in standard precautions that pose risk of infection.
C. Ask the client to undergo a blood test is incorrect because the client has no documented infection, and a blood test is not warranted. Testing the client would be unnecessary, invasive, and not indicated by standard precautions.
D. Wash the gloved hands and then throw the gloves away is incorrect because washing gloves is ineffective in removing pathogens and does not replace proper hand hygiene. Contaminated gloves must be discarded and hands washed thoroughly after removal.
Correct Answer is A
Explanation
Rationale:
A. Verify compatibility and ensure primary line is patent is correct. Before administering a secondary IV medication, the LVN must confirm that the medication is compatible with the primary IV fluid to prevent precipitation, chemical reactions, or reduced drug effectiveness. Ensuring the primary line is patent guarantees that the secondary medication can infuse properly and reach the patient. This step prevents adverse reactions and ensures safe administration.
B. Open the roller clamp fully to start the antibiotic quickly is incorrect because rapid infusion can cause adverse effects depending on the medication. The infusion rate should follow prescribed guidelines, and the roller clamp should only be adjusted after verifying compatibility and line patency.
C. Disconnect the primary IV tubing is incorrect because a secondary (piggyback) infusion is designed to attach to the primary line without disconnecting it. Disconnecting the primary line unnecessarily interrupts fluid therapy and increases the risk of contamination.
D. Lower the primary IV bag below the pump is incorrect because in a piggyback setup, the secondary bag must be placed higher than the primary bag to allow gravity or pump priority flow. Lowering the primary bag would prevent the secondary medication from infusing properly.
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