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 D
Explanation
Choice A rationale
Phenytoin is an anticonvulsant used to control seizures and is not indicated for the treatment of adrenal insufficiency.
Choice B rationale
Calcitonin is used to treat conditions like osteoporosis and hypercalcemia, not adrenal insufficiency.
Choice C rationale
Buspirone is an anxiolytic used to treat anxiety disorders and is not used for adrenal insufficiency.
Choice D rationale
Fludrocortisone is a synthetic corticosteroid that is used to replace aldosterone in patients with adrenal insufficiency. It helps maintain sodium balance and blood pressure.
Correct Answer is ["A","F"]
Explanation
Choice A rationale
Thrombocytopenia, a low platelet count, increases the risk of bleeding and hemorrhage when receiving heparin.
Choice B rationale
Neutropenia, a low white blood cell count, does not directly increase the risk of hemorrhage. It is more related to infection risk.
Choice C rationale
Hypokalemia, low potassium levels, does not directly indicate a risk for hemorrhage. It can cause other complications but not specifically bleeding.
Choice D rationale
Fever is not a direct indicator of hemorrhage risk. It may indicate infection or other inflammatory processes.
Choice E rationale
Hyperglycemia, high blood sugar levels, does not indicate a risk for hemorrhage. It is more related to diabetes management.
Choice F rationale
Dark stools can indicate gastrointestinal bleeding, which is a sign of hemorrhage.
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