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 C

Explanation

A. "What has helped you through difficult times in the past?": Important but not the priority in a potential crisis.

B. "Has anyone in your family committed suicide?": Relevant but not the first question.

C. "Are you thinking about ending your life?": Directly assesses the client's safety and risk for suicide.

D. "Is there anyone you would like involved in your care?": Supports coping but is not urgent.

A. Abdominal circumference B. Gestational age C. Respiratory distress D. UAC E. Feeding method F. 5-minute Apgar score

Correct Answer is ["A","B","C","D"]

Explanation

A. Abdominal circumference: The increase in abdominal circumference by 1 cm (0.4 in) since the prior assessment is concerning and may indicate a complication such as abdominal distension, which could be a sign of necrotizing enterocolitis (NEC) or other gastrointestinal issues. NEC is a serious condition that is common in preterm infants, especially those receiving enteral feedings.

B. Gestational age: Being born at 34 weeks gestation is a significant risk factor. Prematurity increases the risk for complications like respiratory distress syndrome (RDS), infections, and feeding difficulties. Preterm infants are also at risk for problems with thermoregulation, which is why the neonate is on a radiant warmer.

C. Respiratory distress: The presence of substernal retractions, nasal flaring, and an elevated respiratory rate (70/min) indicates respiratory distress. Preterm neonates, especially those born at 34 weeks, are at risk for RDS due to insufficient surfactant production, which can lead to difficulty breathing and hypoxemia.

D. UAC: The umbilical arterial catheter (UAC) is commonly used for monitoring blood pressure and obtaining blood samples in neonates. However, it carries a risk for complications such as infection, thrombosis, and injury to blood vessels. This is an invasive device that could contribute to complications.

E. Feeding method (Continuous breast milk feedings via OG tube): Although feeding via an orogastric tube is a standard method for preterm neonates, it does not pose an immediate risk factor in this case. The method of feeding itself is not a complication risk. However, complications like feeding intolerance or aspiration can arise, which would require further monitoring.

G. 5-minute Apgar score: A 5-minute Apgar score of 7 is considered an acceptable score for a neonate. Although it indicates some initial difficulty, this score does not present a significant risk factor for complications by itself. A lower score would be more concerning, but a score of 7 typically suggests the neonate is transitioning well.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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