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 D
- 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 D
Explanation
A. Inserting an IV is not necessary for a nonstress test, which is a noninvasive procedure.
B. Fasting is not required for a nonstress test, as it does not involve any invasive procedures.
C. C. A nonstress test typically takes around 20 to 30 minutes to complete, not a minimum of 2 hours.
D. This is the correct answer. During a nonstress test, the client is asked to press a button every time they feel their baby move. This helps correlate fetal movements with changes in fetal heart rate, providing information about fetal well-being.
Correct Answer is A
Explanation
A. "I will take a stool softener to prevent constipation." This is correct. Postoperative clients, especially those who are on opioid medications for pain management, are at risk for constipation. Taking a stool softener is a good strategy to prevent this complication after surgery.
B. "I will ask to work the night shift, so I will not be driving in bright sunlight." This is incorrect. Following laser surgery for open-angle glaucoma, clients are typically advised to avoid bright lights and glare, but there is no need to change work schedules. The focus should be on wearing protective sunglasses to shield the eyes from sunlight and glare, not on avoiding daytime work hours.
C. "I will need to use my eye drops for 1 year." This is incorrect. While eye drops may be prescribed to manage intraocular pressure, the duration of use will depend on the specific medication and the client's condition. It is not typically necessary to use them for an entire year after laser surgery, and the client should follow the provider's instructions for tapering or stopping the medication as indicated.
D. "I will need to follow a low-protein diet." This is incorrect. There is no specific dietary restriction for a low-protein diet following laser surgery for open-angle glaucoma. The client should follow a balanced diet as recommended by the healthcare provider.
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