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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Applying light pressure to the inner canthus just after instilling the eye drops is the most effective action to minimize systemic absorption. This technique blocks the nasolacrimal duct, preventing the medication from draining into the systemic circulation through the nasal mucosa. This reduces the potential for systemic side effects.
B. Wiping the eye from the inner to the outer canthus with a sterile saline-moistened cotton ball is a cleaning technique to maintain hygiene but does not impact systemic absorption of the medication.
C. Administering the medication drops directly into the lower conjunctival sac is the correct method for instillation, ensuring proper delivery of the medication to the eye. However, this action does not specifically address systemic absorption.
D. Waiting 5 minutes before instilling drops in the other eye is appropriate to prevent dilution of the medication and ensure its effectiveness in each eye. However, this action does not minimize systemic absorption.
Correct Answer is C
Explanation
A. Incorrect. Allowing the baby to finish a bottle at the next feeding increases the risk of overfeeding and can lead to problems such as excessive weight gain and discomfort.
B. Incorrect. Placing the baby on their stomach after feedings increases the risk of choking and is not recommended. The correct position is to place the baby on their back to sleep.
C. Correct. Newborns typically need to be fed approximately every 2-3 hours, which amounts to about six to eight feedings per day. This statement indicates an understanding of the frequency of feeding required for a newborn.
D. Incorrect. Adding rice cereal to a newborn's bottle is not recommended, especially without medical advice, as it can increase the risk of choking and may not be developmentally appropriate.
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