A nurse is conducting an initial assessment of a client and notices a discrepancy between the client's current IV infusion and the report received during the shift report. Which of the following actions should the nurse take?

Complete an incident report and place it in the client's medical record.

Compare the current infusion with the prescription in the client's medication record.

Contact the charge nurse to see if the prescription was changed.

Submit a written warning for the nurse involved in the incident.

Answer and Explanation

The Correct Answer is B

A. An incident report is appropriate but should not be placed in the client’s medical record.

B. The nurse should first compare the current infusion with the prescription in the client's medication record to ensure the client is receiving the correct medication and dosage.

C. The nurse should verify the prescription before contacting the charge nurse.

D. Submitting a written warning is not the nurse's responsibility and is not appropriate in this situation.

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Correct Answer is B

Explanation

A. Oral hygiene is important but not necessary before postural drainage.

B. Using a bronchodilator such as albuterol before postural drainage helps open the airways, making it easier to clear mucus.

C. Eating a meal before postural drainage can increase the risk of aspiration.

D. Pancrelipase is used to aid digestion and is taken before meals, not before postural drainage.

A. Steatorrhea B. Tinnitus C. Dysphagia D. Fever

Correct Answer is D

Explanation

A. Steatorrhea (fatty stools) is not typically associated with pneumonia; it is more commonly linked to gastrointestinal disorders.

B. Tinnitus (ringing in the ears) is not a common symptom of pneumonia but may be related to ear infections or other conditions.

C. Dysphagia (difficulty swallowing) is not typically a hallmark symptom of pneumonia, though it can occur in severe cases if there is aspiration.

D. Fever is a common symptom of bacterial pneumonia due to the body’s response to infection.

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A nurse is conducting an initial assessment of a client and notices a discrepancy between the client's current IV infusion and the report received during the shift report. Which of the following actions should the nurse take?

Nursing Test Bank

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