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.
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 D
Explanation
A. Oral estrogen supplements may be used in postmenopausal women but are not the first-line preventative measure for UTIs.
B. Soaking in a warm bath can increase the risk of infection by introducing bacteria into the urethra.
C. Emptying the bladder every 6 hours is too infrequent; voiding every 2-4 hours is recommended to prevent urinary stasis.
D. Adequate hydration flushes the urinary system, reducing the risk of bacterial growth and recurrent infections.
Correct Answer is B
Explanation
A. Positioning the knees higher than the hips could increase the risk of hip dislocation.
B. Keeping an abduction pillow between the legs helps maintain the hip in the correct position and prevents dislocation.
C. Raising the head of the bed to a high-Fowler’s position may strain the hip and is not recommended for dislocation prevention.
D. Elevating the affected leg on a pillow may cause internal rotation and increase the risk of dislocation.
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