A client returns to the acute care unit following surgery with 0.9% normal saline infusing at 45 drops/minute through tubing with a drop factor of 60 drops per ml. The postoperative prescriptions include 0.9% normal saline at 75 ml/hour to alternate with Lactated Ringer's solution at 75 ml/hour. An intravenous infusion pump is not available. What action should the nurse implement?
Change the normal saline to a keep open rate until an infusion pump is available.
Increase the rate of the present normal saline infusion to 75 drops per minute.
Leave the normal saline at the current rate until an infusion pump is available.
Switch the saline to Lactated Ringer's solution infusing at 75 drops per minute.
The Correct Answer is C
Choice A: Changing the normal saline to a keep-open rate (KVO) is not appropriate in this situation, as the client has specific fluid orders that need to be followed, and a KVO rate would not provide the prescribed maintenance fluids.
Choice B: Increasing the rate of the present normal saline infusion to 75 drops per minute would not meet the prescription for 0.9% normal saline at 75 ml/hour.
Adjusting the rate this way would require an infusion pump.
Choice C: Leaving the normal saline at the current rate until an infusion pump is available is the most appropriate action. It ensures that the client continues to receive fluids at the ordered rate until the necessary equipment is in place.
Choice D: Switching the saline to Lactated Ringer's solution infusing at 75 drops per minute would not meet the prescribed rate for the normal saline solution. The nurse should follow the specific orders provided.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Teaching clients about the potential side effects of antipsychotic drugs is important, but it is not the most critical aspect of medication administration policy. Monitoring for side effects and adverse reactions is typically the responsibility of healthcare providers and nursing staff.
Choice B: Monitoring all clients receiving antipsychotic drugs for indications of tardive dyskinesia is a crucial standard to include in the policy. Tardive dyskinesia is a serious side effect associated with long-term use of antipsychotic medications, and early detection and intervention are essential to prevent its progression.
Choice C: Ensuring that all clients treated with antipsychotic drugs receive prompt renewals as needed is important for continuity of care, but it is not the primary focus of a policy for administering antipsychotic medications.
Choice D: Documenting all client therapeutic serum levels related to antipsychotic medications is relevant but may not apply to all clients receiving these medications. Monitoring for side effects and adverse reactions is generally more universally applicable and critical to patient safety.
Correct Answer is B
Explanation
Choice A: Obliterating the entry and inserting the correct information may make the charting less clear and may not be considered a best practice in documentation.
Choice B: Drawing one line through the entry and inserting the correct information is a common method for correcting errors in paper documentation. It maintains clarity while indicating that an error was made and corrected.
Choice C: Charting the correct information in the next column may lead to confusion and does not clearly indicate that an error was made and corrected.
Choice D: Notifying the charge nurse that the entry needs to be revised may be necessary in some situations but is not the first step in correcting a charting error. The error should be corrected at the point of documentation.
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