A nurse is caring for a client who is receiving IV fluids. The nurse realizes that the incorrect IV solution is infusing. Which of the following actions should the nurse take?

Complete an incident report.

Allow the current solution to finish infusing, then change the bag.

Document that an error occurred in the client's medical record

Stop the infusion

Answer and Explanation

The Correct Answer is A

- A: Completing an incident report is an important step after addressing any immediate risks to the patient. It is a part of the process to document errors and prevent future occurrences, but it does not take precedence over the patient's immediate safety.
- B: Allowing the current solution to finish could harm the patient, depending on the contents of the IV solution and the patient's condition. Immediate action is required to prevent potential adverse effects.
- C: Documentation in the medical record is crucial, but it should be done after the error has been corrected and the patient's safety is ensured. The immediate priority is to address the error.
- D: Stopping the infusion is the most immediate and appropriate action to prevent further harm to the patient. Once the infusion is stopped, the nurse can then take further steps to correct the error and follow up with the necessary documentation and reports.

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Correct Answer is D

Explanation

A. Incorrect. While limiting sodium intake is important for overall health, it is not typically emphasized specifically during pregnancy unless there are specific medical indications.
B. Incorrect. While fiber is important for digestive health, the focus during pregnancy is usually on ensuring an adequate intake of nutrients like iron, calcium, and folate.
C. Incorrect. While staying hydrated is important during pregnancy, there is no specific recommendation for a set number of glasses of fluids per day. Fluid needs can vary depending on factors such as activity level, climate, and individual health status.
D. Correct. Adequate calcium intake is crucial during pregnancy for the development of the baby's bones and teeth. The recommended daily intake of calcium for adolescents during pregnancy is 1,300 milligrams.

A. Cleanse the perineal area from back to front. B. Wash the perineal area with povidone-iodine twice daily. C. Change the perineal pad with each void. D. Wipe the perineal area with a soft towel. E. Wipe the perineal area with a soft towel.

Correct Answer is C

Explanation

A. Cleansing the perineal area from back to front can introduce bacteria from the rectum to the urinary tract, increasing the risk of infection. Front to back is the recommended direction for cleansing.
B. Washing the perineal area with povidone-iodine twice daily may be too frequent and could potentially irritate the area. Gentle cleansing with warm water is typically recommended.
C. Changing the perineal pad with each void helps to maintain cleanliness and prevent infection by reducing the buildup of moisture and bacteria.
D. Wiping the perineal area with a soft towel is appropriate for gentle cleansing but does not address the importance of changing the perineal pad regularly.

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A nurse is caring for a client who is receiving IV fluids. The nurse realizes that the incorrect IV solution is infusing. Which of the following actions should the nurse take?

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