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. A decreased level of consciousness and vomiting may indicate a potentially serious condition such as increased intracranial pressure, electrolyte imbalance, or metabolic disorder. Immediate assessment and intervention are necessary to determine the cause and provide appropriate treatment.
B. Cellulitis accompanied by a low-grade fever is concerning but may not require immediate attention compared to a decreased level of consciousness and vomiting.
C. A pain rating of 7 after receiving analgesia 30 minutes ago is important to address, but it may not be as urgent as assessing a client with a decreased level of consciousness and vomiting.
D. A blood glucose level of 160 mg/dL in a client with type 2 diabetes mellitus may require monitoring and intervention, but it may not be as urgent as assessing a client with a decreased level of consciousness and vomiting.
Correct Answer is A
Explanation
A. Name and medical record number: This information is unique to each individual and is used to accurately identify patients in healthcare settings, including newborns.
B. Birth date and mother's name: While important for identification, this information alone may not be sufficient to accurately identify a newborn, especially in situations where there may be multiple newborns with similar birth dates or mothers with the same name.
C. Age and diagnosis: Age and diagnosis are important clinical information but are not typically used as primary identifiers for medication administration.
D. Footprints and identification number: While footprints and identification numbers may be used as supplemental identifiers, they are not as reliable or commonly used as name and medical record number for medication administration.
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