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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incorrect. While proper spacing of infant bassinets is important for infection control, this specific distance (24 inches) may not be universally applicable and may vary depending on the facility's protocols.
B. Incorrect. Alcohol-based hand rubs are recommended for hand hygiene in healthcare settings, as they are effective against a broad range of pathogens. They should not be avoided unless contraindicated due to specific circumstances.
C. Correct. Visitors with upper respiratory infections can spread respiratory viruses to vulnerable newborns, so wearing a mask can help prevent transmission.
D. Incorrect. Pumped breastmilk can typically be left at room temperature for a shorter duration, usually up to 4 hours, to maintain its safety and quality.
Correct Answer is A
Explanation
A. This response respects the client's autonomy and right to make decisions about their own healthcare. It acknowledges the client's right to refuse treatment, even if it is recommended by healthcare providers.
B. While it is important to communicate the client's wishes to the healthcare provider, the nurse should not threaten to report the client's decision without their consent. This could undermine trust between the nurse and the client.
C. While it is true that refusing treatment may have medical consequences, this statement may come across as judgmental or coercive. The nurse should provide information about the potential consequences of refusing treatment in a supportive and non-coercive manner.
D. Suggesting that the client consult with a clergyperson before making a treatment decision is not necessarily relevant to the client's medical decision-making process. It may also imply that the decision should be based on religious beliefs rather than personal values and preferences.
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