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 ["D"]
Explanation
Swimming is a low-impact sport that minimizes the risk of injury and joint stress, making it an ideal choice for children with hemophilia. It provides a cardiovascular workout without subjecting the child to excessive physical stress or the risk of trauma that could lead to bleeding. Swimming also promotes muscle strength and coordination without putting significant pressure on the joints.
Now, let's discuss why the other options are not recommended:
a.Basketball
Basketball involves physical contact and has a higher risk of falls, collisions, and potential injuries. These factors increase the likelihood of bleeding episodes for individuals with hemophilia
b.Gymnastics
Gymnastics also carries a high risk of falls, joint stress, and potential injuries. The impact and demanding movements involved in gymnastics can pose a significant risk for children with hemophilia, leading to bleeding complications.
c.Soccer
Soccer is a contact sport that involves running, kicking, and potential collisions with other players. The physical demands and unpredictable nature of the game increase the risk of injury and subsequent bleeding for individuals with hemophilia.
In summary, swimming is the most suitable sport for a school-age child with hemophilia due to its low- impact nature and minimal risk of injury. It promotes physical fitness while minimizing the likelihood of bleeding episodes and joint stress.
Correct Answer is A
Explanation
A. You have the right to refuse the recommended treatment plan.
As a nurse, it’s essential to respect the autonomy and decision-making capacity of your patients. Patients have the right to make informed choices about their own healthcare, including whether to accept or decline treatment recommendations. By acknowledging the patient’s right to refuse treatment, you empower them to be active participants in their care.
B.Option b is not the correct answer because it focuses on informing the provider without addressing the client's concerns or providing guidance.
C.Option c is not the correct answer because it emphasizes the medical consequences of not treating the cancer without acknowledging the client's personal beliefs or values.
D. In cases like yours, it is best to talk with your clergyperson before deciding this.
While option D acknowledges the importance of seeking emotional and spiritual support during difficult decisions, it does not directly address the patient’s right to refuse treatment. As a nurse, your primary responsibility is to respect the patient’s autonomy and provide accurate information about their treatment options. Encouraging open communication with a clergyperson or any other trusted individual can be beneficial, but it should not override the patient’s right to make their own decisions regarding their healthcare.
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