A nurse is caring for a client who received excessive IV fluids in error. Which of the following actions should the nurse take? (Select all that apply.)
Contact the provider.
Report the error to the charge nurse.
Place an incident report in the client’s chart.
Auscultate the client’s lungs.
Check the client for peripheral edema.
Correct Answer : A,B,D,E
Choice A rationale
Contacting the provider is essential to inform them of the error and receive further instructions on managing the client’s condition.
Choice B rationale
Reporting the error to the charge nurse is necessary for proper documentation and to ensure that corrective actions are taken to prevent future errors.
Choice C rationale
Incident reports should not be placed in the client’s chart. They are for internal use to improve safety and quality of care.
Choice D rationale
Auscultating the client’s lungs is important to check for signs of fluid overload, such as crackles or wheezing.
Choice E rationale
Checking for peripheral edema helps assess the extent of fluid overload and its impact on the client’s condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Repeating up to four doses until pain is relieved is incorrect. The correct instruction is to take one tablet at the onset of pain and repeat every 5 minutes if needed, up to a maximum of three tablets in 15 minutes.
Choice B rationale
Storing unused tablets at room temperature is correct. Nitroglycerin tablets should be stored in their original container at room temperature, away from moisture and heat.
Choice C rationale
Taking two tablets at the onset of pain is incorrect. The correct instruction is to take one tablet at the onset of pain and repeat every 5 minutes if needed, up to a maximum of three tablets in 15 minutes.
Choice D rationale
Taking the medication two hours prior to exercise is incorrect. Nitroglycerin should be taken 5 to 10 minutes before an activity that may cause chest pain.
Correct Answer is D
Explanation
Choice A rationale
Limiting caffeine is not the first action the nurse should take. While caffeine can exacerbate symptoms of BPH, it is not the priority action when starting doxazosin IR3.
Choice B rationale
Reporting headaches is important, but it is not the first action the nurse should take. Headaches can be a side effect of doxazosin, but monitoring the patient’s initial response to the medication is more critical.
Choice C rationale
Measuring the client’s intake and output is important for monitoring urinary symptoms, but it is not the first action the nurse should take when starting doxazosin IR3.
Choice D rationale
Administering the medication at bedtime is the correct first action. Doxazosin can cause dizziness and hypotension, especially after the first dose, so taking it at bedtime can help minimize these effects.
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