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 ["A","B","C"]
Explanation
Choice A rationale
Potassium level should be reviewed because captopril can cause hyperkalemia due to its effect on aldosterone secretion.
Choice B rationale
WBC with differential should be reviewed because captopril can cause neutropenia or agranulocytosis, especially in patients with renal impairment or collagen vascular disease.
Choice C rationale
BUN level should be reviewed because captopril can affect renal function, leading to increased BUN levels.
Choice D rationale
Hemoglobin level is not typically affected by captopril, so it is not a priority for review.
Choice E rationale
Glucose level is not typically affected by captopril, so it is not a priority for review.
Correct Answer is D
Explanation
Choice A rationale
Immediate-release exenatide pens should be discarded 30 days after the first use, not two months. This ensures the medication remains effective and free from contamination.
Choice B rationale
Exenatide is administered subcutaneously, not intramuscularly. The preferred injection sites are the abdomen, thigh, or upper arm.
Choice C rationale
Open exenatide pens should be stored at room temperature, but this is not the most critical aspect of patient education. Proper storage ensures the medication’s stability and effectiveness.
Choice D rationale
Immediate-release exenatide should be taken one hour before morning and evening meals to optimize its glucose-lowering effects by enhancing insulin secretion in response to meals.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.