A nurse is caring for a large group of patients. She checks on her post-op patient and starts the IV fluids. While programing the pump the nurse is interrupted by another staff member. Three two hours later the nurse rounds and finds that the patient is short of breath, requiring more oxygen and has crackles in her lungs.

The nurse then realizes that the IV fluids were running at twice the ordered rate. What should the nurse do next?

Assess the client

Notify the nurse manager

Complete an incident report

Call the client’s provider

Answer and Explanation

The Correct Answer is A

A. Assess the client.

This is the immediate priority. The nurse should assess the patient's current condition to determine the extent of the impact of the error on the patient's health, focusing on respiratory status, vital signs, and signs of fluid overload.

B. Notify the nurse manager.

Once the patient has been assessed and stabilized, the nurse should inform the nurse manager or supervisor about the error. This helps ensure appropriate reporting, investigation, and follow-up actions.

C. Complete an incident report.

After assessing and stabilizing the patient, the nurse should document the error in an incident report. Incident reports are important for organizational learning, identifying patterns, and implementing improvements to prevent future errors.

D. Call the client’s provider.

If the patient's condition is deteriorating or requires immediate attention, the nurse should contact the healthcare provider to discuss the situation, report the error, and collaborate on necessary interventions.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. Dorsal surface of the foot:

The skin on the dorsal surface of the foot may have more pigmentation, making it potentially more challenging to detect cyanosis in individuals with dark skin.

B. Pinnae of the ears:

The ears may have variable pigmentation, and the presence of hair can affect the visibility of cyanosis. The skin on the pinnae may not be as thin as the skin on the dorsal surface of the hand.

C. Dorsal surface of the hand

When assessing for cyanosis in a client with dark skin, the nurse should examine areas with less pigmentation or areas where the skin is thin. The dorsal surface of the hand is often a suitable site, as it is less pigmented and can show bluish discoloration if cyanosis is present.

D. Conjunctivae:

The conjunctivae (the mucous membranes lining the inner surface of the eyelids and covering the white part of the eyes) are not a reliable site for assessing cyanosis in individuals with dark skin. Mucous membranes may not show cyanosis as prominently as the skin.

A. Wait 30 min and return to measure the oral temperature B. Provide the client a sip of warm water, wait 5 min, and measure the temperature. C. Document that the nurse was unable to measure the client’s temperature. D. Determine if the client has eaten or drank within the last 15 minutes. E. Use an alternate route (ie. axillary, rectal) to take the client’s temperature

Correct Answer is ["B","D","E"]

Explanation

A. Wait 30 min and return to measure the oral temperature:

Waiting 30 minutes may not be necessary. It's more practical to take immediate steps to address potential factors affecting the reading.

B. Provide the client a sip of warm water, wait 5 min, and measure the temperature:

This can be a reasonable and practical approach to stimulate blood flow in the oral cavity and achieve a more accurate oral temperature reading.

C. Document that the nurse was unable to measure the client’s temperature:

Before documenting an inability to measure the temperature, the nurse should attempt appropriate interventions, such as warming the oral cavity or using an alternate route

D. Determine if the client has eaten or drank within the last 15 minutes:

Eating or drinking something cold shortly before taking an oral temperature can result in a lower reading. Checking for recent intake is important to ensure the accuracy of the measurement.

E. Use an alternate route (i.e., axillary, rectal) to take the client’s temperature:

If the oral temperature reading remains difficult to obtain or is not reliable, using an alternate route may be necessary. However, this depends on the client's condition, the reason for the temperature measurement, and the healthcare facility's protocols.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

Correct Answer is C

Explanation

A nurse is measuring a client’s oral temperature. The thermometer reads 33 C (91.4F). Which of the following actions should the nurse take? (Select all that apply)

Correct Answer is ["B","D","E"]

Explanation

A nurse is caring for a client who has an electrical burn. With the client’s permission, the nurse is answering questions from the family about his status. Which of the following responses should the nurse make?

A nurse is assessing a client’s circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?

Order: Ampicillin (Principen) 150 mg PO every 6 hours Available: Ampicillin (Principen) 125mg per 5 ml How many mL of ampicillin are needed for one dose? ( Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero. TYPE THE ANSWER ONLY, no label )

A nurse in the ER is caring for a patient who had fallen at home. She reviews the blood pressure reading of 160/80 mm Hg. The client denies any history of hypertension. Which of the following actions should the nurse take first?

A nurse is completing a client’s history and physical examination. Which of the following information should the nurse consider subjective data?

A nurse is completing the initial admission assessment and history for a critical client. Which of the following is the priority action for the nurse to take?

When you receive the shift report, you learn that your patient has no special skin care needs. You are surprised during the bath to observe reddened areas over bony prominences. What action is appropriate?