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.
Remove the IV catheter.
The Correct Answer is D
d. Remove the IV catheter.
Explanation:
The correct answer is d. Remove the IV catheter.
If the nurse realizes that the incorrect IV solution is infusing, it is essential to take prompt action to prevent harm to the client. Removing the IV catheter is the appropriate course of action to stop the infusion of the incorrect solution.
Option a, completing an incident report, may be necessary after the immediate situation has been addressed, but it should not be the nurse's first action. The priority is to stop the incorrect solution from infusing.
Option b, allowing the current solution to finish infusing and then changing the bag, is not the correct action. Continuing the infusion of the incorrect solution can potentially harm the client and must be stopped immediately.
Option c, documenting that an error occurred in the client's medical record, is important, but it should be done after taking immediate action to stop the incorrect solution from infusing. Documentation should include the details of the incident, any actions taken, and the client's response.
By promptly removing the IV catheter, the nurse stops the infusion of the incorrect solution and prevents further harm to the client. Afterward, the nurse should assess the client for any adverse effects, inform the appropriate healthcare providers, and follow the facility's policies and procedures for reporting incidents and documenting the error.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
After a patient dies, postmortem care includes preparing them for family viewing . The nurse should place the body in the supine position, with the arms at the sides and the head on a pillow. Then elevate the head of the bed 30 degrees to prevent discoloration from blood setling in the face.
The other options are not correct because:
b) The nurse should cleanse the client's body while wearing appropriate personal protective equipment (PPE) based on indications for isolation precautions, not necessarily sterile gloves.
c) If the patient wore dentures and your facility’s policy permits, gently insert them; then close the mouth.
d) The nurse should close the eyes by gently pressing on the lids with their fingertips. If they don’t stay closed, place moist coton balls on the eyelids for a few minutes, and then try again to close them. Surgical tape is not mentioned as necessary .
Correct Answer is A
Explanation
Answer: A
Rationale:
A) Ampicillin: Ampicillin is contraindicated for this client because it belongs to the penicillin class of antibiotics. Since the client is allergic to penicillin, administering ampicillin could trigger an allergic reaction, which could range from mild rash to severe anaphylaxis.
B) Erythromycin: Erythromycin is a macrolide antibiotic and can be used as an alternative for clients who are allergic to penicillin. It is often prescribed for group B streptococcus infections in penicillin-allergic clients, making it a suitable option in this case.
C) Cefazolin: Cefazolin is a cephalosporin antibiotic and is generally considered safe for clients with a penicillin allergy, except in cases of severe penicillin allergies. Cross-reactivity is low, and cefazolin can be an appropriate choice for treating group B streptococcus.
D) Clindamycin: Clindamycin is a lincosamide antibiotic and is often used for clients with penicillin allergies. It is effective against group B streptococcus and does not belong to the penicillin or cephalosporin classes, making it a suitable option for this client.
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