A nurse is caring for a client who has a prescription for a 250 mL IV fluid bolus. The nurse administers a 500 mL IV bolus.

Which of the following actions should the nurse take first?

Obtain the client's vital signs.

Notify the healthcare provider.

Document the incident in the client’s medical record.

Assess the client for adverse reactions.

Answer and Explanation

The Correct Answer is D

Notify the healthcare provider.
The nurse should first notify the healthcare provider of the error in administering the IV bolus.
This is important because the healthcare provider can assess the situation and provide guidance on how to proceed.
Choice A is not the correct answer because obtaining the client’s vital signs is important but not the first action the nurse should take.
Choice C is not the correct answer because documenting the incident in the client’s medical record is important but not the first action the nurse should take.
Choice D is not the correct answer because assessing the client for adverse reactions is important but not the first action the nurse should take.

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Correct Answer is D

Explanation

The first two actions the nurse should take are to obtain a sputum culture and a chest X-ray.
These tests can help diagnose the cause of the client’s symptoms and guide treatment.
Choice A is wrong because administering antibiotics and bronchodilators should only be done after a diagnosis has been made.
Choice B is wrong because airborne precautions and isolation may not be necessary depending on the cause of the client’s symptoms.
Choice C is wrong because cough suppressants and antihistamines may not be appropriate treatments depending on the cause of the client’s symptoms.

A. Change the tubing set every 72 hr. B. Aspirate residual volume every 4 hr. C. Flush the tubing with 10 mL of water every 2 hr. D. Heat the formula to 40.5° C (105° F).

Correct Answer is A

Explanation

According to a study published on PubMed, it is appropriate to change alimentation tubes and feeding bags every 72 hours rather than every 24 hours.

Choice B, Aspirate residual volume every 4 hr, is not necessary for continuous enteral feedings through a gastrostomy tube.

Choice C, Flush the tubing with 10 mL of water every 2 hr, is not necessary for continuous enteral feedings through a gastrostomy tube.

Choice D, Heat the formula to 40.5° C (105° F), is not necessary for continuous enteral feedings through a gastrostomy tube.

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A nurse is caring for a client who has a prescription for a 250 mL IV fluid bolus. The nurse administers a 500 mL IV bolus. Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is caring for a client who is receiving continuous enteral feedings through a gastrostomy tube. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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A nurse is caring for a client who has a prescription for a 250 mL IV fluid bolus. The nurse administers a 500 mL IV bolus.

Which of the following actions should the nurse take first?